EmblemHealth is one of America’s largest not-for-profit health insurers, serving more than three million people in the New York tristate area. With an 80-year legacy of serving New York communities, EmblemHealth offers a full range of commercial and government-sponsored health plans to employers, individuals, and families.

We started back in the 1930s, at the height of the Great Depression. Out of hard times, the idea of health insurance was born — a system that would protect everyday people from financial misfortune if they had an accident or illness. Two companies from those early days of health insurance, Group Health Incorporated (GHI) and Health Insurance Plan of Greater New York (HIP), would later merge and become EmblemHealth. And after 80 years, our purpose as a not-for-profit is still the same — to provide quality, affordable health insurance for New Yorkers and their families.

The EmblemHealth family of companies provides insurance plans, primary and specialty care, and wellness solutions. The family of companies covers the whole health journey, starting with affordable coverage through EmblemHealth, and ConnectiCare, a leading health plan in Connecticut. The family of companies also includes medicinal practices AdvantageCare Physicians and BronxDocs, occupational health clinic EmblemHealth Health@Work, EmblemHealth Family Dental, and WellSpark Health, a barrier-breaking digital wellness company.

As a family of companies with deep community roots, EmblemHealth Neighborhood Care and ConnectiCare Centers offer free wellness and community resources. Together, the family of companies creates healthier futures for customers and communities.

We think of ourselves as an 80-year-old start-up — big enough to offer the stability and benefits of a major corporation, with a ferocious commitment to innovation, collaboration, and flexibility. We believe in what we’re doing. And we’re looking for passionate people to join us.

Summary Of Position

• Lead a team of data analyst within Pharmacy Analytics team, directing the reporting and analytics functions effectively across Pharmacy and the other departments in the enterprise.
• Help team to Analyze, calculate, validate and reconcile Medicare Part D Prescription Drug Event (PDE) files.
• Partner with other Emblem and Pharmacy Benefit Manager (PBM) to ensure timely and accurate PDE file submissions.
• Participate in related audits, make recommendations to improve PDE results, and prepare actionable reports used by leadership to monitor and oversee PDE submission and Part D financial payment accuracy.
• Maintain a current understanding of CMS guidance on PDEs and Emblem Customers’ Part D coverage and benefit plans in order to accurately analyze Part D claims and PDE data and supports all components of PDE data and Part D financial payment reconciliation.
• Help team to build a repository of repeatable high value queries for business consumption which meet all reporting requirements.

Principal Accountabilities

• Lead PDE resolution activities with minimal 99.95% acceptance rate target.
• Work across the organization to identify and resolve the issues causing PDE errors.
• Proactively manage day-to-day PDE activities and hold/lead meetings with Emblem Enrollment Team and PBM for timely solutions.
• Perform timely analysis and reconciliation of PDE entries rejected by CMS, including adjustments related to eligibility, accumulators, cost sharing, gap discounts and LICS (low income subsidy) status.
• Identify gaps in the benefit and formulary design structure to ensure prompt resolution of all setup issues that impact claims adjudication and therefore PDEs.
• Review PDE error reports and analyze pharmacy claims and PDE reject data as needed to identify root cause of PDE errors.
• Establish a positive working relationship with other Emblem Enrollment and PBM teams to timely resolve errors and correct/adjust PDE records.
• Understand PBM’s PDE process to align the PDE fixes/updates with PBM’s timelines.
• Understand eligibility feed process to assist with identifying potential issues and report them to timely.
• Ensure continuous improvement of Part D claims and PDE accuracy through root cause analysis of errors and recommending systems and procedure enhancements as appropriate.
• Assist in project management tasks (e.g., prepare business and technical requirements for error resolution, project status updates, checklists, and timelines of key stages to complete corrective actions).
• Troubleshoot Acumen Tickets related to PDE issues.
• Ensure successful adherence to annual CMS deadlines, and internal timelines for PDE reconciliation, reporting, testing, and corrections.
• Participate in Medicare Part D financial audits, as needed.
• Perform timely download, compilation, reconciliation and maintenance of PDE related guidance, data and reports
• Other duties as assigned

Relevant Work Experience, Knowledge, Skills, And Abilities

• A minimum of 5 years of data analytics experience required (R)
• Advanced SAS knowledge (R)
• Strong management experience (R)
• Advanced organizational knowledge (R)
• Knowledge of regulatory and accreditation requirements (R)
• Knowledge of Health Insurance Portability and Accountability Act (HIPAA) (R)
• Able to establish Strong QA process (R)