This position is responsible for providing advanced analytical support for pharmacy operations, financial trending, budget/forecast modeling and ongoing identification of areas for improvement, actions needed and issues or opportunities requiring management attention within Horizon NJ Health.
Reporting and analysis of Pharmacy Key Performance Metrics (KPM).
Establish query and analysis of outcomes reporting for pharmacy clinical and financial (MCR) based programs.
Develop forward looking pharmacy forecasting models that account for high cost impact drugs in the pipeline, pending patent losses in key therapeutic categories as well as drug inflation and the Consumer Price Index (CPI).
Daily reporting and analysis of all pharmacy financials by Line of Business (LOB).
Development and analysis of Specialty Pharmacy specific cost modeling reports to establish impact of drug inflation, utilization, and population influence.
Review and validation of all pharmacy cycle payment reports and authorize release of claims payments to all pharmacy network providers.
Assist with reporting and management of Pharmacy -pass-through- financial receivable process.
Establish a formal pharmacy trending reporting portfolio to be presented to the pharmacy management team and the actuarial team on a regular basis.
Assist with reconciliation of pharmacy encounter files and associated receivable balances.
Establish a daily pharmacy dashboard report which outlines the status of multiple pharmacy key metrics which will allow for immediate identification of any potentially aberrant claims, financial activity or any system operations integrity issue.
Analysis of ongoing Pharmacy Prior Authorization trending and associated medical cost savings by drug and therapeutic category.
Reporting and analysis of Pharmacy lock-in Program quality and financial impact.
Generate quarterly DMAHS and DOBI regulatory reports for review and sign-off.
Financial modeling of all therapeutic drug categories, and all newly FDA approved medications to support review and decision making by HNJH Pharmacy and Therapeutic Committee.
Analyze pharmacy utilization patterns and call attention to significant changes in outpatient and medical based pharmacy drug utilization or expenditures requiring management attention.
Support departmental Medication Therapy Management Program (MTM) via integration of pharmacy and medical claims and reporting of member outcomes.
Develop formal forecasting reports that can be utilized for purposes of actuarial modeling, forecasting and budgeting by finance personnel.
Support all other pharmacy data analytics, financial management and reporting needs.
Requires knowledge of popular brand and generic drug names.
Requires working knowledge of managed care principles.
Requires knowledge of common medical terminology.
Requires understanding of National Drug Code (NDC).
Requires understanding interdependencies among data.
Requires knowledge of common IT terminology.
Prefers knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation.
Prefer strong knowledge of SAS and SQL systems.
Skills and Abilities:
Requires excellent verbal and written communications skills.
Requires the ability to work in a high volume environment under direct guidance or supervision.
Requires good analytical skills and the ability to use sound judgment and resolve problems.
Requires good interpersonal skills.
Requires excellent PC skills and the ability to manage applicable software.
Requires ability to recognize incongruous data on claim submissions and determine patterns of irregularities.
Requires strong analytical abilities and the ability to report findings accurately.
Requires strong interpersonal skills and the ability to interact with all management levels.
Requires the ability to utilize logic in problem solving.
Knowledge of database concepts and applications, proven quantitative and analytical skills.
Requires strong database management skills.
Bachelor’s degree in Healthcare Management, Business, Pharmaceutical Administration, technical discipline preferred or relevant work experience required in lieu of degree.
Prefers 3 years experience in health insurance.
Prefers minimum of 5 year experience in third party prescription program claim adjudication or benefit administration.
Requires advanced competency in Access, Word and Excel applications.
Requires 5 years data reporting experience.
Prefers working knowledge of SAS and SQL systems.
The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
About Horizon Blue Cross Blue Shield of New Jersey
At Horizon Blue Cross Blue Shield of New Jersey, the collaboration between diverse professionals is one reason people are making NJ's largest health insurer their favorite place to work. With more than 3.8 million members, our goal is to provide individuals and employers in New Jersey with convenient access to quality, affordable health care.