Senior Data Analyst, Quality Review - Medicare...

We’re hiring a Senior Data Analyst to join the Government Pharmacy Programs Department! The Senior Data Analyst, Quality Review - Medicare Pharmacy Claims is responsible for ensuring accurate, compliant adjudication of Medicare Part D and Medicare Part B pharmacy claims. This role performs detailed quality oversight, validates benefit and pricing logic, ensures adherence to CMS regulations, and identifies systemic issues that impact claims accuracy, financial performance, and member outcomes., + 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

• 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.

Bonus Points (Preferred Qualifications)

• 5+ years of Medicare pharmacy claims, PBM, or managed care experience

• Direct experience with Medicare quality review, compliance, auditing, or PDE support strongly preferredStrongexpertisein Medicare Part D pharmacy claims adjudication , including PDE requirements and CMS benefit rules

• Working knowledge of Medicare Part B drug billing , HCPCS, andpharmacy-to-medicalclaim integration

• Solid understanding of CMS regulations, including:

• Cost-sharingand benefit phase logic

• LIS and subsidy calculations

• Formulary management and UM edits (PA, ST, QL)

• Advanced analytical skills with experience performing claimanalysesanderror trending

• Proficiencyin Excel; experience withprescription adjudicationsystemsandMedicare reporting tools preferred

• Strong documentation, communication, andcross-functionalcollaboration skills

• Pharmacy Technician certification or equivalent pharmacy background is a plus, Business Analysis, Business Data Analysis, Business Intelligence (BI), Cloud Applications, Code Collaborator, Communication, Consulting, Data Warehousing (DW), Health Insurance Industry, Peer Development, Problem Solving, Statistical Models, Structured Query Language (SQL)

• The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community

• Work-life balance, flexibility, and the autonomy to do great work

• 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

• 401k match

Where You’ll Work

Our Hybrid Flex approach is built on presence with a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplace that’s flexible, connected, and future focused.

In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

$89,174.00 - $142,679.00

It’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. We offer more than health insurance our customers can count on. We’re committed to better health and better health care - in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.

Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.

Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Authorization to Work in the United States

We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.

Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at HR.Staffing@bcbsnc.com .

Blue Cross NC is a Hybrid Flex company. Whether the role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any of our approved states:

Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming