Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.


To protect the health and safety of our workforce, members, patients, and the communities we serve, the EmblemHealth family of companies require all new employees to be fully vaccinated for COVID-19. Exemption/reasonable accommodations may be granted because of 1) a qualifying medical condition or disability that makes getting the vaccine unsafe for the individual, or 2) objection on the basis of sincerely held religious beliefs and/or practices.

Lead Data Analyst

📁
Manager & Professional
💼
EmblemHealth
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Summary of Position

•    Lead a team of data analyst within Pharmacy Analytics team, directing the reporting and analytics functions effectively across Pharmacy and the other departments in the enterprise. 
•    Help team to Analyze, calculate, validate and reconcile Medicare Part D Prescription Drug Event (PDE) files. 
•    Partner with other Emblem and Pharmacy Benefit Manager (PBM) to ensure timely and accurate PDE file submissions.
•    Participate in related audits, make recommendations to improve PDE results, and prepare actionable reports used by leadership to monitor and oversee PDE submission and Part D financial payment accuracy. 
•       Maintain a current understanding of CMS guidance on PDEs and Emblem Customers’ Part D coverage and benefit plans in order to accurately analyze Part D claims and PDE data and supports all components of PDE data and Part D financial payment reconciliation.
    Help team to build a repository of repeatable high value queries for business consumption which meet all reporting requirements.   

Principal Accountabilities

•    Lead PDE resolution activities with minimal 99.95% acceptance rate target. 
•    Work across the organization to identify and resolve the issues causing PDE errors. 
•    Proactively manage day-to-day PDE activities and hold/lead meetings with Emblem Enrollment Team and PBM for timely solutions.
•    Perform timely analysis and reconciliation of PDE entries rejected by CMS, including adjustments related to eligibility, accumulators, cost sharing, gap discounts and LICS (low income subsidy) status. 
•    Identify gaps in the benefit and formulary design structure to ensure prompt resolution of all setup issues that impact claims adjudication and therefore PDEs.
•    Review PDE error reports and analyze pharmacy claims and PDE reject data as needed to identify root cause of PDE errors. 
•    Establish a positive working relationship with other Emblem Enrollment and PBM teams to timely resolve errors and correct/adjust PDE records.
•    Understand PBM’s PDE process to align the PDE fixes/updates with PBM’s timelines. 
•    Understand eligibility feed process to assist with identifying potential issues and report them to timely.
•    Ensure continuous improvement of Part D claims and PDE accuracy through root cause analysis of errors and recommending systems and procedure enhancements as appropriate.
•    Assist in project management tasks (e.g., prepare business and technical requirements for error resolution, project status updates, checklists, and timelines of key stages to complete corrective actions).
•    Troubleshoot Acumen Tickets related to PDE issues.
•    Ensure successful adherence to annual CMS deadlines, and internal timelines for PDE reconciliation, reporting, testing, and corrections. 
•    Participate in Medicare Part D financial audits, as needed.
•    Perform timely download, compilation, reconciliation and maintenance of PDE related guidance, data and reports, including:
     -     CMS files (e.g., PDE guidance memos, CSSC training, Acumen tickets)
     -     PDE monitoring reports (e.g., PDE FIN report, PDE Management Reports, and PDE Error reports).
     -     PDE data (e.g., CMS response files, CMS rejects, PBM pre-edit rejects)
•    Process PDE response files and reject data in SAS, compile and maintain outputs in SAS PDE databases to be used for reporting and analyses.
•    Validate and reconcile PDE data to PDE financial and management reports.
•    Assist management on special projects. 
•    Support New Plan Year implementation testing. 
•    Support CMS audits.
•    Support financial statement audits.
•    Provide support to cascaded projects and goals.
•    Regulatory Reporting:
     -    456Medicaid Managed Care Operating Report
     -    Special Investigation Unit reports
     -    Retiree Drug Subsidy Reports for USA, NYSHIP, MTA

•    Other reports:
     -    OMT
     -    Upload and analyze cash receipt rebate files from ESI
     -    STARS and PPA reports
     -    ALPHA GH3, NonGH3, CCI Medicare, CCI HIX/Commercial table creation and maintenance
     -    Inpharmative data analysis and manipulation until vendor is sunset
•    Various Ad Hoc Reports
•    Other activities, including creating guides and training new team members.
•    Prepare and maintain actionable PDE dashboards and reports for leadership to be used in monitoring and overseeing PDE submission and Part D financial payment accuracy. Examples include:
     -    Bi-monthly and Monthly PDE errors and acceptance rate dashboard and summary reports
     -    PDE and Part D Financial payment reconciliation 
     -    Summary of PDE Acumen ticket findings, member impact, and corrective actions
     -    Updates to Emblem Compliance Online Monitoring Tool/Reports for PDE metrics
     -    Summary of PDE related audit findings, member impact, and corrective actions
     -    Summary CMS guidance updates on PDE calculations and reporting rules
•    Prepare other Part D reporting, as needed (e.g., HPMS reporting, Annual Part D Direct and Indirect Remuneration reporting, PDE reports requested by other Emblem teams and approved by PDE Task Force Leaders).
•    Assist in development of PDE submission, reconciliation, and analytics standards related documentation and training materials.
•    Supervise and mentor the professional staff in the team. 
•    Support efforts to recruit top tier talent into the department, develop and train these individuals into a high-performance team.
•    Maintain current understanding of the following PDE-related topics:
     -    PDE calculation and reporting rules
     -    Medicare Part D coverage rules (e.g., Defined Standard Benefit, Employer Group Waiver Plans)
     -    Part D financial payment rules (e.g., Coverage Gap Discount Program, LICS subsidy, Reinsurance subsidy)
•    Serve as subject matter expert for PDE-related topics (above) and participate in interdepartmental meetings and PBM conference calls.

Education, Training, Licenses, Certifications

•    Bachelor’s degree in Business, Finance, Health Administration, Math, Sciences, or IT from a four-year college or university. 
•    Master’s Degree a plus but not required

Relevant Work Experience, Knowledge, Skills, and Abilities

•    A minimum of 5 years of  data analytics experience required (R)
•    Advanced SAS knowledge (R)
•    Strong management experience (R)
•    Advanced organizational knowledge (R)
•    Knowledge of regulatory and accreditation requirements (R)
•    Knowledge of Health Insurance Portability and Accountability Act (HIPAA) (R)
•    Able to establish Strong QA process (R)

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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