The Membership & Benefits Analyst will be a subject matter expert and information technology analyst responsible for analyzing, designing and delivering solutions that support pharmacy benefits and / or membership record processing in pharmacy systems. This position requires informatics and business expertise on pharmacy benefits (particularly with PBMs) and membership interfaces.
The successful candidate will have a proven background in working collaboratively in and with highly matrixed, cross-functional teams on a national basis. Knowledge of batch and real-time interfaces of industry standards and the various customized Kaiser Membership interfaces is highly desired. Ability to assess downstream system impacts is required.
Expertise in pharmacy benefit designs for products such as Medicare, HDHP / HSA, Self Funding, and Value-Based products highly desired. Working knowledge of NCPDP standards highly desired. Knowledge of standard PBM services such as network management, call center support, and clinical / formulary support preferred.
Partnering with IT, Business, and vendor stakeholders to identify requirements and potential solutions for new development as well as troubleshooting issues in a production environment is required. Candidate must have strong verbal and written skills.
Responsibilities
- Build stakeholder credibility as KP's IT Subject Matter Expert in pharmacy membership and pharmacy benefits. Stakeholders include but are not limited to Pharmacy, Membership, and HealthPlan (Medicare, HDHP, and other product lines).
- Gather and analyze business stakeholder requests for new membership interface and pharmacy benefits development.
- Develops quality and acceptance criteria for software. Ensure quality criteria are established and met before software is delivered
- Identify opportunities for operational improvement through troubleshooting issues in a production environment.
- Adhere to HIPAA and Kaiser guidelines on management of PHI and MPII
- Adhere to SOX requirements / controls
- Familiarity with SAS 70 Type II reporting and controls
- Transform requirements into solutions by partnering with IT software engineering teams and vendor software development groups
- Maintain and build relationships with internal IT, business operations, regional departments, and vendors, to deliver standard software solutions in support of membership interfacing activities
- Support business operations in production stabilization of pharmacy membership interfaces and pharmacy benefits.
- Maintain current working knowledge of industry standards (i.e., NCPDP, HL7, and X12).
Qualifications:
Basic Qualifications:
- Bachelors degree or equivalent relevant experience in Pharmacy Operations, Health Care Administration, Public Health Administration required
- Minimum of 8 years experience working in healthcare providing some experience in managed care environments and / or pharmacy operations
- Minimum of 8 years of experience documenting functional requirements, analyzing business processes, and developing business cases to support IT solutions.
- Minimum of 5years experience working in developing software solutions in a non-profit, corporate or consulting environment
- Solid technical and business skills in software solution development activities including Waterfall and Agile frameworks.
- Demonstrated ability to conduct and interpret quantitative and qualitative analysis and present key findings
- Ability to define and effectively frame complex, multi-dimensional pharmacy issues
- Strong written, presentation, and interpersonal communications skills
- Strong problem resolution skills
- Strong time management and project management skills
- Adaptable to fast-paced and fast changing environments
- Ability to stay current with technological changes
- Demonstrated ability to interact and work within high performing teams with diverse responsibilities
Preferred Qualifications:
- Considered functional expert in field within Kaiser Permanente.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.