Senior Data Analyst, Quality Review - Medicare Pharmacy Claims Part D & Part B)
Remote Flex - North Carolina, United States
R
USD 89K-142K Senior-level Full Time
Tasks
- Conduct root cause analysis on quality findings
- Develop quality metrics dashboards and trend reports
- Identify claims adjudication errors pricing benefit configuration formulary status and CMS rules
- Implement corrective actions with Compliance IT operations and PBM teams
- Mentor peers and develop Medicare quality standards SOPs and training
- Perform quality reviews of Medicare pharmacy claims
- Provide Medicare pharmacy claims subject matter expertise
- Review Part B drug claims for HCPCS coding units and allowable charges
- Support internal and external audits with findings impact and remediation documentation
- Validate Low Income Subsidy cost sharing calculations
- Validate MAC list pricing
- Validate MOOP accumulations
- Validate Medicare Part D benefit phase logic
- Validate PDE data elements and claim submission logic
Perks/Benefits
- 401k match
- Adoption Assistance
- Career Development Programs
- Flexibility
- Medical, dental, and vision coverage
- Parental leave
- Surrogacy Assistance
- Tuition reimbursement
- Work-life balance
Skills/Tech-stack
Business Intelligence | Cause analysis | Claim adjudication | Data Analysis | Data Visualization | Data Warehousing | Error Trending | Excel | Formulary management | HCPCS | Healthcare Data | Low Income Subsidy | MAC Pricing | MOOP | Medicare | Medicare Part B | Medicare Part D | PDE | Part B | Part D | Prior authorization | Quality Assurance | Quantity Limits | Root Cause Analysis | Root cause | SQL | Step therapy | Utilization management
Education
Bachelor of Engineering | Bachelor of Science | Master of Science
Roles
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