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.

Pharmacy Analytics Leader

📁
Director and Equivalent
📅
190OF Requisition #
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Lead the Pharmacy Analytics team, directing the Rebates & PDE functions effectively across Pharmacy and the other departments in the enterprise. (PDE data capture prescription drug events for to CMS. The PDE data are not the same as individual drug claim transactions but are summary extracts using CMS-defined standard fields.  Accountable to improve the PDE acceptance rate and company finances and maximize DIR (Direct and Indirect Remuneration) savings to reduce premium costs and increase Medicare plan membership.  Perform strategic and operational analytics, using data analytics tools efficiently to inform the business in support of strategic decision making, measuring the effectiveness of program implementations.  Build a repository of repeatable high value queries for business consumption which meet all state and CMS reporting requirements.  Lead and mentor a team of talented data analysts.  Manage the medical contract rebate reporting process, ensuring accurate and timely collection of rebates due to EmblemHealth and ConnectiCare.  Audit pharmacy rebate process maximizing rebate pass through from Express Scripts (ESI).  Report progress quarterly.  Define and execute solutions regarding delinquent/inaccurate payment from Pharma and Express Scripts.

Responsibilities:

Lead team of Data Analysts responsible for strategic and operational data analytics using both Pharmacy and Medical data. 
  • Identify analytics solutions to business challenges.
  • Assess the value of proposed and implemented strategies, identify improvement opportunities through the use of data analytics.
  • Measure operational process efficiency and effectiveness. Collaborate with business owners to achieve objectives and goals.
  • Provide information, not just data using visualization tools such as Tableau to enhance the value of the information provided.
  • Develop team members to increase effectiveness of the team.
  • Develop project dashboard and provide weekly updates to Pharmacy Leadership.
  • Create a suite of operational reports allowing business owners to self-serve and validate compliant processing and/or opportunities for improvement. 
  • Build real-time UM reporting capabilities for optimal workflow through the UM team.
Utilization Management (UM) Reporting
  • Maintain a process of daily, weekly, monthly and quarterly reporting.
  • Work with UM vendor for streamlined reporting solutions.
  • Create audit universes for CMS Program Audit, Timeliness Monitoring and various other CMS audits. 
  • Create reports for NCQA accreditation project. 
  • Report the results to Pharmacy leadership to help them monitor timeliness of coverage determination reviews.
Medicare Prescription Data Event (PDE) Management:
  • Achieve optimal reimbursement from CMS with a PDE acceptance rate of 99.95%+ for each of our 6 CMS contracts.
  • Identify root cause of rejected PDEs and works cross functionally to resolve and eliminate recurrence of rejects.
  • Direct the ESI PDE team on prioritization of PDE reject resolution.
  • Oversee ESI performance to ensure conformance to CMS guidance.
  • Create a user friendly PDE dashboard to inform management of revenue secured through accurate, timely PDE processing.
  • Develop PDE Analyst for continued growth and contribution to the organization.
Builds, submits and attests to accuracy of the annual and re-stated Direct and Indirect Remuneration (DIR) Submission. 
  • Lead a cross functional team (pharmacy, finance, actuary, vendors) to deliver the annual and re-stated DIR reports for 2 plan years concurrently.
  • Identify strategies to maximize DIR contribution to reduce premium costs and increase Medicare membership. 
  • Validate the accuracy of the DIR report including the contributions from vendor organizations by using audit tools and data analytics.
  • Interface with CMS on DIR submissions, attestation and any follow up required.  
Federal and State Reporting:
  • Accountable for all pharmacy reporting required by the Federal and State Government for Medicare, Medicaid and Exchange plans.
  • Lead vendor in preparation of quarterly and annual Retiree Drugs Subsidy (RDS) reporting, ensuring accurate content and optimal subsidies for our clients.
  • Manage the Pharmacy portion of the Medicaid Managed Care Operating Report (MMCOR).
Manage Annual Health Plan Management System (HPMS) Data Submission.
  • Develop quarterly review process. 
  • Establish strong QA process for accurate reporting. 
Pharmacy and Medical Drug Rebate Management
  • Responsible for managing medical rebate processing and submission
  • Perform QA to ensure the accuracy of the data 
  • Work with internal and external partners to understand reporting needs and ensures the timely completion of the reports. 
  • Responsible for maintaining databases for easy reporting solutions
Relentlessly pursue innovative data analytics solution, including predictive analytics. 

Follow the changes in the Health Care Industry closely and helps EmblemHealth modernization.
 
Flexible to work on complex special projects to support department and company needs such as Formulary Cost Analysis, Medical UM cost analysis.

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.
Qualifications:
  • Bachelor’s Degree required
  • Advanced degree in related field preferred
  • A minimum of 10 years of data analytics and SAS coding experience required
  • Advanced SAS knowledge required
  • Strong management experience required
  • Advanced organizational knowledge required
  • Knowledge of regulatory and accreditation requirements required
  • Knowledge of Health Insurance Portability and Accountability Act (HIPAA) required
  • Able to establish Strong QA process required

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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