Wellmark Blue Cross and Blue Shield ยท 9 hours ago
Pharmacy Quality Analyst (Open to hiring at Sr level)
Des Moines, IA
Full-time
Hybrid
Mid, Senior Level
2+ years expWellmark Blue Cross and Blue Shield is a mutual insurance company focused on member well-being and sustainability. The Pharmacy Quality Analyst will drive quality assurance within the Pharmacy team, conducting reviews to ensure compliance and supporting continuous improvement initiatives.
Financial ServicesHealth InsuranceInsurancePersonal Health
No H1B
Responsibilities
Lead assigned quality reviews of complex PBM configurations and internal pharmacy operations, ensuring alignment with Wellmark standards and regulatory requirements (e.g., validating coding accuracy across formulary, benefits, network, and prior authorization setups)
Conduct root cause analysis of quality issues and recommend actionable improvements. Collaborate with internal teams to implement enhancements that improve operational efficiency and member outcomes
Collaborate with internal stakeholders and/or vendor subject matter experts on quality issues identified, ensuring timely remediation and documentation
Develop and maintain reporting utilizing Excel and potentially PowerBI to monitor quality trends and performance metrics. Analyze data to identify risks, opportunities, and the impact of quality initiatives. Present findings to leadership
Provide guidance and training to team members and stakeholders on pharmacy quality standards and processes. Represent the pharmacy team in enterprise-wide quality and compliance initiatives
Provide back-up assistance in cross-functional projects and testing efforts related to benefit design and system enhancements. Support the development of test plans and documentation for unique or complex configurations
Assist in the development and delivery of communications related to quality findings and PBM updates. Ensure messaging is clear, accurate, and aligned with Wellmark's customer experience principles
Maintain accurate records of quality reviews, coding validations, and issue resolutions. Ensure adherence to NCQA, CMS and internal compliance standards
Other duties as assigned
Qualification
Required
Associate degree or direct and applicable work experience
Minimum of 2 years of related pharmacy operations work experience from within managed care, health care, pharmacy, PBM, customer service or similar environment. Experience should reflect knowledge of pharmacy practice (e.g., drug name, NDC, GPI), pharmacy claims processing and/or UM tools (e.g., formulary, prior authorization, step therapy)
Experience with systems analysis or testing to include writing and executing test cases
Knowledge of drug coding and concepts (e.g. NDC, GPI, J codes, MediSpan, etc.)
Ability to perform, document, and or guide others through a series of related steps and takes action to improve existing conditions and processes
Ability to identify issues or inconsistencies; obtains relevant information, relates and compares data from different sources and identifies alternative solutions
Knowledge of applicable regulatory standards
Effective critical thinking and analysis skills. Ability to evaluate information and implement appropriate solutions
Demonstrated strong written and verbal communications skills with the ability to clearly and concisely communicate complex concepts with internal and external stakeholders
Strong interpersonal skills with the ability to build relationships of collaboration and trust with different business areas. Viewed as a subject matter expert and go-to resource
Strong collaboration skills, with the flexibility to adapt to different stakeholders
Proficiency with Microsoft Office, including Excel; use of pivot tables, charts, and formulas is preferred. Technical aptitude to learn new software quickly
Self-starter with strong organizational skills and the ability to independently balance priorities in a fast-paced, dynamic environment. Flexible and adaptable to change
Bachelor's degree or equivalent applicable experience
3+ years of pharmacy operations experience in managed care, PBM, or health care settings
Demonstrated experience in quality assurance, data analysis, and process improvement
Strong knowledge of pharmacy practice (e.g., drug coding, formulary, prior authorization, step therapy)
Experience leading root cause analysis and implementing strategic improvements
Advanced proficiency in Microsoft Excel (pivot tables, charts, formulas) and reporting tools
Strong written and verbal communication skills, with the ability to present complex information to leadership
Experience mentoring or coaching others
Understanding of NCQA standards, CMS regulations, and internal compliance protocols
Demonstrates strategic judgment in balancing competing deadlines, proactively mitigating risks, and ensuring timely delivery of high-impact work
Preferred
Bachelor's degree
Certified Pharmacy Technician
Experience with PBM coding and configuration
Prior experience leading cross-functional projects or enterprise initiative
Company
Wellmark Blue Cross and Blue Shield
Wellmark Blue Cross and Blue Shield and its subsidiaries provide health coverage to more than 2 million members in Iowa and South Dakota.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
John Forsyth
Chief Executive Officer
Andrew Neller
Deputy Chief Information Security Officer
Recent News
2022-02-18
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