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 & Rebate Leader

📁
Director and Equivalent
📅
191CQ Requisition #
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Direct the team in producing high quality data analytics. Inform strategic decision-making by all business centers using data analytics tools efficiently, measuring the effectiveness of program implementation, and building a repository of repeatable high value queries for business consumption.  Manage and meet all state and CMS reporting requirements. Design improvements to effectively increase the PDE acceptance rate and company finances, maximize DIR savings to reduce premium costs and increase Medicare plan membership.  Create and perform strategic and operational analytics, using strong risk assessment skills to enhance internal controls.  Lead, build and mentor talented team of employees.

Responsibilities:
  • Manage the Analytics and Reporting Team responsible for PDE Oversight and Reporting, HPMS Reporting, DIR Reporting, MMCOR Reporting, Client Reporting, RDS Reporting, MTM Support, Rejected Claims Reporting and Various Clinical Reports. 
  • Create integrated information and analysis using Pharmacy and Medical Data.
  • Direct and maintain work plan and QA/sign-off process for each of the major reporting projects.
  • Develop and provide data and technical support to Government Program Teams such as ABII, Precluded Prescribers, Transition Drop Letters, Rejected FIR Transactions, ESRD and Hospice. 
  • Strengthen the decision-making process with savings opportunities such as steering Pharmacy Benefits to Medical Benefits.
  • Automate solutions for Pharmacy tasks, working with the Emblem Transformation Team to streamline Pharmacy reporting.
  • Develop data to support RFPs, including Federal Employees Benefit Plan, working closely with the Underwriting team. 
  • Ensure profitability of sales/renewals demonstrating financial guarantees provided by PBM.  
  • Act as primary liaison with benefit consultant organization, leading the scheduled market check to improve rates with incumbent PBM and/or identifies cost savings opportunities through other PBM resource. 
  • Modernize and automate reporting.
  • Direct complex analysis, calculations, validation and reconciliation of Medicare Part D Prescription Drug Event (PDE) files. 
  • Ensure timely and accurate PDE file submissions, participate in related audits, make recommendations to improve PDE results. 
  • Oversee actionable reports used by leadership to monitor PDE submission and Part D financial payment accuracy.
  • Resolve errors in data and reporting in a timely manner, in partnership with other departments. 
  • Maintain a current understanding of CMS guidance on PDEs and EmblemHealth’s customer Part D coverage and benefit plans. 
  • Analyze Part D claims and PDE data and support all components of financial payment reconciliation.
  • Direct the historical PDE re-openings from Pharmacy perspective. 
  • Resolve historical PDE errors in preparation for PDE re-openings.
  • Oversee the resolution of PDE current and old plan year rejects.   
  • Develop and maintain PDE deletion tracker and reports to Finance for reserves. 
  • Support Finance and Actuary with Annual CMS Financial Reconciliations and Financial Re-openings.
  • Resolve issues raised during PDE preparation and hold monthly meetings with Pharmacy Leadership.
  • Analyze and identify the compliant and non-compliant Pharmacy members for Stars measures.
  • Identify data solutions for the Pharmacy Quality Team to improve CMS Star-rating programs. 
  • Provide data support to in-house MTM program.
  • Manage relationship with Finance, which includes custom reporting, process walk-though, budget support and CMS Financial Reconciliations support.  Meets Finance team frequently to review the issues and outstanding items.
  • Liaison between Pharmacy and Accruals Team. Reports Pharmacy accruals on a monthly basis.  
  • Liaison between Pharmacy and Actuary Team.
Qualifications:
  • Bachelor’s Degree required
  • Advanced degree in related field preferred
  • Strong knowledge of SQL Coding, Python, Tableau required
  • Advanced Coding and Python knowledge required
  • A minimum of 10 years of Data experience required, including 5 years of management and leadership experience, preferably in a healthcare setting preferred
  • Advanced organizational knowledge 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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