Three to five years of healthcare experience in a managed care setting is required.
Proficiency in data analytics, including SAS and SQL, is required.
Knowledge of Medicaid and Medicare benefits, enrollment and billing, and provider contracting is required.
Knowledge of CPT, ICD-9, ICD-10, HCPC, DRG, revenue, and RBRVS is required.
Proficiency in Microsoft Excel, Word, and PowerPoint, and experience using a claims processing system or comparable database software, are required.
Effective oral, written, and interpersonal communication skills are required.
Ability to multitask efficiently, effectively, and in a timely manner is required.
Strong organizational skills and work ethic are required.
The role requires the ability to meet stated physical requirements, including standing, sitting, lifting or pushing/pulling up to 50 pounds, bending or squatting, safely using stairs and walking, agility and fine motor skills, visual reading and writing, listening and speaking clearly, and cognitive ability for decision-making and analysis.
Responsibilities
Extract, compile, and analyze pharmacy claims data from the Pharmacy Benefit Manager and internal data warehouse systems to support departmental reporting and monitoring.
Develop, maintain, and distribute recurring and ad hoc reports, dashboards, and pivot table analyses, including drug-spend trends, high-utilizer caseloads, and therapeutic-class and HICL/GPI-level utilization, using Excel and SQL.
Prepare monthly and quarterly utilization, cost, and trend reports for pharmacy leadership, clinical programs, and interdepartmental stakeholders.
Validate data quality and integrity across pharmacy claims platforms, the Enterprise Data Warehouse, and clinical documentation systems; identify and resolve discrepancies.
Support timely and accurate CMS Part D reporting, including enrollment and disenrollment, Medication Therapy Management, grievances, coverage determinations, redeterminations and reopenings, and Drug Utilization Review controls.
Assist in administering the Drug Management Program by compiling OMS/MARx data, tracking At-Risk and Potentially At-Risk Participant case-management timelines, and preparing required notices and supporting documentation.
Collect and prepare pharmacy-related data for NYSDOH, OMIG, and CMS inquiries, audits, and submissions, ensuring accuracy, completeness, and compliance with regulatory deadlines.
Support formulary transition activities and manufacturer discount program workflows, including tracking and reporting rebate and discount data accuracy.
Monitor and report on Star Ratings and Part D quality measures, including medication adherence and medication safety, to support performance-improvement initiatives.
Lead analysis, validation, monitoring, and reporting of Medicare Part D Prescription Drug Event data submitted through the CMS Drug Data Processing System; support data-quality initiatives, regulatory compliance, encounter-data integrity, operational reporting, and stakeholder engagement to ensure accurate processing and submission of Part D pharmacy claims data.
Assist management in responding accurately and on time to internal and external audit inquiries, including inquiries from government agencies such as OMIG, CMS, and DOH.
Investigate discrepancies or anomalies in pharmacy claims and reporting data, conduct root-cause analysis, and recommend process improvements to enhance accuracy and efficiency.
Maintain clear documentation of data-collection methods, reporting processes, and workflows to support audit readiness and knowledge continuity.
Collaborate with Clinical Pharmacy, Compliance, Quality, and IT teams to identify reporting needs, refine data extracts, and build sustainable reporting solutions.
Address data and reporting inquiries from internal and external stakeholders promptly and professionally.
Perform other duties as assigned.
Desired Qualifications
Claims adjudication experience and understanding of claims PPS are strongly preferred.
Certified Professional Coder certification is a plus.
JOB PURPOSE:
The Pharmacy Data and Reporting Analyst plays a key role in supporting the Pharmacy department by collecting, analyzing, and reporting on pharmacy claims and clinical program data. This position is responsible for developing and maintaining recurring and ad hoc reports, monitoring drug utilization and cost trends, and supporting compliance with CMS Part D, NYSDOH, and OMIG reporting requirements. This role requires strong data analytics skills, a working knowledge of pharmacy benefit management (PBM) data, and the ability to translate complex data sets into actionable insights that support clinical, financial, and regulatory decision-making.
JOB RESPONSIBILITIES:
Pharmacy Claims Data & Reporting:
Extract, compile, and analyze pharmacy claims data from the Pharmacy Benefit Manager (PBM) and internal data warehouse systems to support departmental reporting and monitoring needs.
Develop, maintain, and distribute recurring and ad hoc reports, dashboards, and pivot table analyses (e.g., drug spend trends, high-utilizer caseloads, therapeutic class and HICL/GPI-level utilization) using Excel, SQL.
Prepare monthly and quarterly utilization, cost, and trend reports to support pharmacy leadership, clinical programs (e.g., palliative care, homebound, high-risk/high-impact reviews), and interdepartmental stakeholders.
Validate data quality and integrity across pharmacy claims platforms, the Enterprise Data Warehouse (EDW), and clinical documentation systems, identifying and resolving discrepancies.
Regulatory & Compliance Reporting:
Support timely and accurate completion of CMS Part D reporting requirements, including enrollment/disenrollment, Medication Therapy Management (MTM), grievances, coverage determinations/redeterminations/reopenings, and Drug Utilization Review (DUR) controls.
Assist in the administration of the Drug Management Program (DMP) by compiling OMS/MARx data, tracking At-Risk and Potentially At-Risk Participant (ARB/PARB) case management timelines, and preparing required notices and supporting documentation.
Collect and prepare pharmacy-related data for NYSDOH, OMIG, and CMS inquiries, audits, and submissions, ensuring accuracy, completeness, and compliance with regulatory deadlines.
Support formulary transition activities and manufacturer discount program workflows, including tracking and reporting on rebate and discount data accuracy.
Monitor and report on Star Ratings and Part D quality measures (e.g., medication adherence, medication safety) to support performance improvement initiatives.
Lead the analysis, validation, monitoring, and reporting of Medicare Part D Prescription Drug Event (PDE) data submitted through the CMS Drug Data Processing System (DDPS). Support data quality initiatives, regulatory compliance, encounter data integrity, operational reporting, and stakeholder engagement to ensure accurate processing and submission of Part D pharmacy claims data
Audit Support & Process Improvement:
Assist management with timely and accurate responses to internal and external audit inquiries, including those from government agencies (OMIG, CMS, DOH).
Investigate discrepancies or anomalies in pharmacy claims and reporting data, conduct root cause analysis, and recommend process improvements to enhance accuracy and efficiency.
Maintain clear documentation of data collection methods, reporting processes, and workflows to support audit readiness and knowledge continuity.
Collaborate with Clinical Pharmacy, Compliance, Quality, and IT teams to identify reporting needs, refine data extracts, and build sustainable reporting solutions.
Maintain a high level of customer service for internal and external stakeholders, addressing data and reporting inquiries promptly and professionally.
Other duties as assigned.
Schedule: 8:30AM – 5:30PM
Weekly Hours: 40
QUALIFICATIONS:
Education: Bachelor's degree required. Certified Professional Coder a plus.
Experience:
3-5 years of healthcare experience, managed care setting is required.
Proficiency in data analytics, i.e. SAS, SQL is required.
Claims adjudication and understanding of claims PPS is strongly preferred.
Knowledge of Medicaid and Medicare benefits, enrollment and billing, and provider contracting is required.
Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS
Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system or comparable database software.
Effective oral, written, and interpersonal communication skills are required.
Able to multitask efficiently, effectively, and timely.
Strong organizational skills and work ethic.
Detail-oriented, professional and collaborative, a great team player.
Physical Requirements
Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:
Standing – Duration of up to 6 hours a day.
Sitting/Stationary Positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.
Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
Audio Hearing and Motor Skills (Language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.
Disclaimer:Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.
We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.
Salary Range (Min-Max):
$85,000.00 - $90,000.00 (2 - 5 years of experience) $90,000.00 - $95,000.00 (5+ years of experience)
Every application is reviewed by our recruitment team. We do not use AI to make hiring decisions or automatically reject applicants. All employment decisions are based on job-related qualifications and applicable employment laws.