Note: The job is a remote job and is open to candidates in USA. Blue Cross NC is seeking a Senior Data Analyst to join their Government Pharmacy Programs Department. The Senior Data Analyst, Quality Review – Medicare Pharmacy Claims will ensure accurate and compliant adjudication of Medicare pharmacy claims, conducting quality oversight and validating benefit and pricing logic while adhering to CMS regulations.

Responsibilities

• Perform comprehensive quality reviews of Medicare Part D and Part B pharmacy claims, including retail, mail order, LTC, specialty, and medical‑benefit drug claims
• Validate accurate application of:
• Medicare Part D phases (Deductible, Initial Coverage, Catastrophic)
• Low‑Income Subsidy (LIS) cost‑sharing
• MOOP accumulations
• PDE data elements and claim submission logic
• MAC list pricing
• Pharmacy discounts and dispensing fee accuracy by pharmacy type
• Identify irregular prescribing and/or dispensing patterns for investigation and referral to PBM, internal audit and SIU teams
• Review Part B drug claims for correct HCPCS coding, units of service, allowable charges, and coordination with medical claims
• Identify claim adjudication errors related to pricing, benefit configuration, formulary status, utilization management edits, and CMS rules
• Partner with Compliance to ensure claims accuracy consistent with CMS guidance, Medicare manuals, and plan sponsor requirements
• Support internal and external audits (CMS program audits, CTM, PDE validation, RADV support activities) by identifying findings, impact analysis, remediation documentation, and Corrective Action Plans
• Conduct root cause analysis on quality findings; partner with Compliance, IT, operations, and PBM teams to implement corrective actions
• Develop and maintain quality metrics, dashboards, and trend reports related to Medicare claims accuracy and risk
• Serve as a subject matter expert for Medicare pharmacy claims processing
• Provide guidance and mentorship to peers and colleagues, and contribute to Medicare‑specific quality standards, SOPs, and training materials

Skills

• Bachelor's degree or advanced degree (where required)
• 5+ years of experience in related field
• In lieu of degree, 7+ years of experience in related field
• 5+ years of Medicare pharmacy claims, PBM, or managed care experience
• Direct experience with Medicare quality review, compliance, auditing, or PDE support strongly preferred
• Strong expertise in Medicare Part D pharmacy claims adjudication, including PDE requirements and CMS benefit rules
• Working knowledge of Medicare Part B drug billing, HCPCS, and pharmacy-to-medical claim integration
• Solid understanding of CMS regulations, including: Cost-sharing and benefit phase logic, LIS and subsidy calculations, Formulary management and UM edits (PA, ST, QL)
• Advanced analytical skills with experience performing claim analyses and error trending
• Proficiency in Excel; experience with prescription adjudication systems and Medicare reporting tools preferred
• Strong documentation, communication, and cross-functional collaboration skills
• Pharmacy Technician certification or equivalent pharmacy background is a plus

Benefits

• Annual Incentive Bonus*
• 401(k) with employer match
• Paid Time Off (PTO)
• Competitive health benefits and wellness programs
• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• Work-life balance, flexibility, and the autonomy to do great work

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