PBM Claims and QA Analyst

For the Controls & QA, the key would be someone who comes from a PBM/Pharmacy Claims processing role.
Titles could be:
Claims Processing
Benefit Design
Benefits Analyst
Claims Configuration

Key words will be: PBM or Pharmacy, Claims, processing, SQL, testing, validation, Excel, Macros.

Will need to have 9+/10 Comm skills.

They will pull data with SQL, into flat files parse it/validate in Excel or SQL (macros and SQL scripting, queries, joins etc a huge plus). Note: This is not a SQL developer role but need to see if benefits setups are correct. Not testing data flow but verifying claims data.

Ideally they will help build a library of SQL queries
Be able to do batch analysis/testing
Work with IT team on issues.
Test Claim Data
Test benefit plan designs
Test processing through adjudication engine.
Convert to FTE 56K-84kmax ideal is ~ 70k
They have 2 roles open with the title controls and QA.
Any candidate with the following skills will be considered:
Claims processing (PBM/pharmacy/pharmacy benefits management)
PBM
SQL
Excel (V-lookup, Macros, Pivot tables)
Experience with EDI a huge plus.
Data integrity/compare/validate data across two systems
QA

ROLE AND RESPONSIBILITIES
Our Client, a rapidly growing Pharmacy Benefit Management (PBM) company, is seeking a QA & Controls Analyst for their claims systems.
PBM/Healthcare QA experience
Claim processing experience
Support Go-Live claim testing
Validate / Compare data across two systems
Senior experience with Excel Spreadsheet and Macros
Daily detailed synopsis of workload
Senior SQL experience

ROLE AND RESPONSIBILITIES
The Controls and QA Analyst is responsible for developing, monitoring, assessing, reviewing, and recommending changes to Liviniti's quality and control procedures to ensure the highest quality standards in accordance with company policies. The Controls and QA Analyst works closely with the Claims Processing Director, the Claims Processing team, and the other members of the Controls and QA team. This role is heavily analytical and requires critical thinking skills.
Responsible for providing quality assurance for internal processes and suggesting additional additions, when appropriate.
Understands and defines the performance and quality standards expected of Claims Processing employees.
Evaluates quality standards from an objective point of view and ensures the proper checks and balances are applied to all parts of the Claims Processing procedures.
Responsible for being fully trained in both the claims processor and other internal programs so an adequate knowledge base can be used when evaluating and following procedures.
Participate in the design of procedures of but not limited to reimbursement audits, group/plan design, in- house ticket, group/plan changes, SOC audits, and QA testing in internal program(s).
Remain current on plan knowledge, policies, processes, procedures, and systems knowledge of Liviniti's procedures.
Contribute to the continual evaluation, identify, and solve for inefficiencies of existing processes and procedures.
Create a culture of continuous improvement.
Potentially responsible for providing training internal teams on new procedures implementing updated quality controls.
Assist with group/plan design, when necessary.
Managing tickets and accurately capture/categorize necessary trend information.
Support projects and initiatives which drive department strategy.
Share and communicate pertinent information with internal team members and internal partners.
Utilizing an in depth understanding of technical principles, theories, and concepts in the field of quality to perform a thorough root cause and corrective action analysis.
Assist with User Acceptance Testing for internal program development before enhancements are released.
Familiar with external teams regarding test platform claims data/enhancement requests.
Analyze and interpret test claims for processing and adjudication results to ensure configuration accuracy.
Assist with other departments troubleshooting plan/benefit configuration related questions through claims testing.
Report findings and follow through with resolution resulting from claims analysis.
Document results and follow through resolution within departments tracking system.
Participate in a culture of continuous improvement, open door policy and internal support system.
Be an example for work ethic, growth, positivity, and external team communications.
Ensure daily tasks performed by team meet quality and expectations of dept leaders.
Continuous involvement in claims analysis with QA team.
Abide by all obligations under HIPAA related to Protected Health Information (PHI).
If a HIPAA violation is discovered, whether individually or by another, you must report the violation to the Compliance Officer and/or Human Resources.
Attend, complete, and demonstrate competency in all required HIPAA Training offered by the company.
Flexibility to understand, appreciate and embrace that this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

REQUIRED SKILLS AND COMPETENCIES
Problem Solving/Analysis
Critical Thinking
Time Management
Communication
Objectivity
Technical Expertise
Perform root cause analysis
Strong written and verbal communication skills
Exceptional listening and analytical skills
Proficient in Word, Excel, and PowerPoint for presentations and reports required

REQUIRED EDUCATION AND EXPERIENCE
2 years of PBM experience in a Quality Analysis and Controls setting OR
3 years of PBM experience in Benefit Design execution or Implementation at a high level