[Remote] Senior Data Analyst, Quality Review - Medicare Pharmacy Claims Part D & Part B)

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.ResponsibilitiesPerform comprehensive quality reviews of Medicare Part D and Part B pharmacy claims, including retail, mail order, LTC, specialty, and medical‑benefit drug claimsValidate accurate application of:Medicare Part D phases (Deductible, Initial Coverage, Catastrophic)Low‑Income Subsidy (LIS) cost‑sharingMOOP accumulationsPDE data elements and claim submission logicMAC list pricingPharmacy discounts and dispensing fee accuracy by pharmacy typeIdentify irregular prescribing and/or dispensing patterns for investigation and referral to PBM, internal audit and SIU teamsReview Part B drug claims for correct HCPCS coding, units of service, allowable charges, and coordination with medical claimsIdentify claim adjudication errors related to pricing, benefit configuration, formulary status, utilization management edits, and CMS rulesPartner with Compliance to ensure claims accuracy consistent with CMS guidance, Medicare manuals, and plan sponsor requirementsSupport internal and external audits (CMS program audits, CTM, PDE validation, RADV support activities) by identifying findings, impact analysis, remediation documentation, and Corrective Action PlansConduct root cause analysis on quality findings; partner with Compliance, IT, operations, and PBM teams to implement corrective actionsDevelop and maintain quality metrics, dashboards, and trend reports related to Medicare claims accuracy and riskServe as a subject matter expert for Medicare pharmacy claims processingProvide guidance and mentorship to peers and colleagues, and contribute to Medicare‑specific quality standards, SOPs, and training materialsSkillsBachelor's degree or advanced degree (where required)5+ years of experience in related fieldIn lieu of degree, 7+ years of experience in related field5+ years of Medicare pharmacy claims, PBM, or managed care experienceDirect experience with Medicare quality review, compliance, auditing, or PDE support strongly preferredStrong expertise in Medicare Part D pharmacy claims adjudication, including PDE requirements and CMS benefit rulesWorking knowledge of Medicare Part B drug billing, HCPCS, and pharmacy-to-medical claim integrationSolid 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 trendingProficiency in Excel; experience with prescription adjudication systems and Medicare reporting tools preferredStrong documentation, communication, and cross-functional collaboration skillsPharmacy Technician certification or equivalent pharmacy background is a plusBenefitsAnnual Incentive Bonus*401(k) with employer matchPaid Time Off (PTO)Competitive health benefits and wellness programsMedical, dental, and vision coverage along with numerous health and wellness programsParental leave and support plus adoption and surrogacy assistanceCareer development programs and tuition reimbursement for continued educationWork-life balance, flexibility, and the autonomy to do great workCompany OverviewIt's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. It was founded in 1933, and is headquartered in Durham, North Carolina, USA, with a workforce of 5001-10000 employees. Its website is https://www.bluecrossnc.com/.