Pharmacy Analyst - Remote

Your career starts now. We’re looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

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JOB SUMMARY :

The Pharmacy Analyst applies advanced subject matter knowledge to complex business issues and is regarded as a subject matter expert. The Analyst frequently contributes to the development of new ideas and methods and works on complex problems / projects where the analysis of situations or data requires an in-depth evaluation of multiple factors. The incumbent exercises independent judgment within defined policies and practices to determine the best method for accomplishing work and achieving objectives. The Analyst leads and provides expertise to functional project teams and may participate in cross-functional initiatives, understanding and supporting strategic process improvement initiatives and goals, while working collaboratively with management. To maintain, review, and provide consultation on basic to moderately complex customer benefits. The benefit claims analyst also analyzes claims reports to identify trends and issues and present recommendations.

RESPONSIBILITIES :

Regulatory Knowledge : Maintains strong knowledge of Exchange-Related Benefit Designs, including familiarity with Benefit Configurations with both Medical and Pharmacy-Combined Benefit Designs. Ensure compliance with CMS, state-based Exchange regulations, HIPAA, and ACA-related pharmacy benefit requirements. Monitor pharmacy benefits for compliance with benchmark plan formularies, Essential Health Benefits (EHB) coverage, and cost-sharing standards. Collaborate with internal and external business areas to maintain a current working knowledge of contractual, regulatory, internal, and informational metrics, requirements, and service levels.

• Project Management : Manage multiple projects and group implementations, maintain appropriate documentation, monitor deadlines, and provide time / resource estimates. Maintains knowledge of Coordination of Benefits and determining pharmacy payment liability between multiple payers. Organizes, documents, and maintains benefit design specifications in a standardized format. Responsible for supporting test plans and scenarios and reviewing manual and batch testing in User-Acceptance Testing and Production / Live Testing environments in the claims-processing software.
• Implementation & System Integration : Oversee the implementation and configuration of pharmacy benefit platforms to support Marketplace Exchange operations. Coordinate PBM integrations, real-time benefit tools, and electronic prior authorization systems. Ensure seamless data exchange between pharmacy systems and Marketplace enrollment, eligibility, and claims processing platforms.
• Research & Evaluation : Respond to requests, conduct research, and document findings. Identifies and researches benefits, eligibility, and claims-related issues. Monitors and reports claims activity based on benefit set-up to ensure accurate processing according to the client's approved requirements.
• Process Improvement : Review current reporting processes, identify opportunities for efficiencies, and communicate with stakeholders to determine an appropriate course of action before enacting changes.
• Cross-functional Collaboration : Serve as a liaison between business units in meetings and cross-functional teams. Ensure the timely updates and integrity of the knowledge tools and plan materials. Interact with the pharmacy benefits manager, ACFC IS teams, eligibility vendor, and Exchange business unit.
• Data Analysis :  Identify, research, and analyze data outliers and / or irregularities in operations reports. Utilize real-time reports to identify and mitigate risks proactively. Make recommendations to management based on trend analysis, regulatory impacts, and performance metrics. Review and write comprehensive reports, identify alternatives, and make recommendations to management upon request.
• Audit & Reporting : Participation, including leading audits related to benefit or claims activity. Audit and maintain shared / stored operations reports to ensure they are comprehensive, accurate, and defensible. Conduct system testing and quality assurance to ensure accurate formulary management, drug tiering, and cost-sharing structures. Monitor pharmacy claims data for discrepancies, fraud, waste, and abuse (FWA) risks, ensuring regulatory adherence. Perform other related duties and projects as assigned by the Exchange and Pharmacy leadership as required. This can include strategy support, presentations, and mentoring activities. Adheres to all AmeriHealth Caritas and PerformRx policies and procedures. Regularly reviews and adheres to standard operating guidelines, desktop procedures, checklists, templates, and memorandums issued to the department. Creates and supports an environment that fosters teamwork, cooperation, respect, and diversity. Establishes and maintains positive communication and professional demeanor with PerformRx employees and customers at all times. Demonstrates and supports commitment to corporate goals and objectives.

EDUCATION / EXPERIENCE

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable being themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, Paid Time Off (PTO), holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more.

Generous paid time off and paid volunteer time off.

Employer-matched 401(k) and additional non-elective contributions, starting on day one.

Medical, dental, and vision plans — with coverage starting on day one.

Employee assistance programs, fitness reimbursements, nutrition counseling, and more.

Employer-paid life insurance, with opportunities to purchase additional coverage.

Employer-paid short-term disability coverage and long-term disability coverage.

Tuition assistance, including reduced tuition at certain schools.

Financial assistance with adoption, including paid time off.

Flexible spending and health savings accounts to pay for qualified expenses.

Discount programs on entertainment, travel, and more.