Specialty Pharmacy Analyst

Washington, DC, United States

Under the general direction of the Specialty Pharmacy Director, and working closely with other pharmacy leaders, including the Specialty Pharmacy Lead Pharmacist, this position supports the operational efficiency of specialty pharmacy services by coordinating fiscal management activities, performing data analysis, maintaining departmental dashboards, statistics and reports, and auditing 340B utilization, purchase records and realized 340B cost savings, across all system sites and retail pharmacies. This role is responsible for developing, preparing and maintaining quality data analytics that will be utilized by leadership and management across various settings and promote new opportunities for the organization, thus enhancing efficiency and resulting in optimal revenue. Database development, project management, cost accounting, and IT skills will be employed to work with clinical pharmacists, residents, medical staff, and pharmacy administration.

The incumbent takes responsibility for duties relating to payer audits and audit-related recoveries, understanding pharmacy audit procedures, elements, and findings, and having knowledge of payer audit processes while providing hands-on audit assistance, tools, and reference material for customers. This position is also responsible for network risk identification, assessment, reporting, and remediation. The role oversees the business's compliance risk monitoring mechanisms, including evaluation, assessment, and management.

The Specialty Pharmacy Analyst assists in maintaining the specialty pharmacy business in accordance with departmental standards, internal and external reporting requirements, accreditation standards, and pharmacy laws and regulations. S/he will organize, supervise, direct, evaluate, and validate data collection and reporting functions to ensure the provision of accurate, efficient, and appropriate specialty pharmacy services. The Analyst reports to internal and external stakeholders for purposes of inclusion in specialty pharmacy networks, accreditation, and overall business management.

Qualifications:

Minimum Education

Bachelor's Degree Bachelor's degree in Computer Science, Finance, Economics, Specialty Pharmacy, or related field(Required)

Master's Degree MBA or Concentration in business, marketing, communications, or a related field (Preferred)

Minimum Work Experience

5 years Health care experience required (Required)

3 years 3+ years of data analysis required (Required)

3 years Prior retail pharmacy experience preferred (Preferred)

Required Skills/Knowledge

Ability to successfully work with a diverse customer base both externally and internally, including but not limited to manufacturer accounts representatives, office staff, and patients.

Experience in providing excellent customer service skills to internal and external customers and able to react with a strong sense of urgency when needed to prevent or resolve issues.

Excellent verbal and written communication skills.

Ability to prioritize workload and maintain attention to detail.

Ability to work well in a team environment and provide support to other team members.

Ability to manage intake of issues via phone and email and segregate urgent from non-urgent.

Ability to identify solutions to problems quickly and clearly communicate results in a timely fashion.

Excellent organizational skills.

Ability to multitask and remain flexible in a fast-paced work environment.

Exceptional analytical skills and ability to work independently with general direction.

Strong computer skills in order to operate effectively with company systems and programs.

Familiarity with reporting analytics and forecasting tools such as SQL, Tableau, PowerBI, etc.

Proficient with Microsoft Office (Outlook, Word, and Excel).

Knowledge of third-party insurance billing practices, federal and state regulations with regard to billing and reimbursement, internal billing structure, and billing procedures.

Experience with patient assistance programs.

Experience with healthcare enterprise analytics.

Experience with pharmacy management software.

Required Licenses and Certifications

Pharmacy Technician (CPhT) DC/MD (Preferred)

Advanced 340B Operations 180 Days (Required)

Prior Authorization Certified Specialist (PACS) or similar Prior Authorization certification preferred (Preferred)

Functional Accountabilities

Performance Reporting & Analytics: Report on Specialty Pharmacy Services (SPS) quality and performance indicators, such as revenue, number of prescriptions, margin, capture rate, phone metrics, consumer satisfaction, dispensing errors, delivery errors, prior authorization approval rate, time, turnaround time, and others as required.

Analyze various opportunities through financial modeling.

Ensure all SPS reporting requirements are met to maintain SPS network contracts.

Develop analytic dashboards that will improve SPS understanding and performance.

Develop participation reports to document utilization, savings, exceptions, or discrepancies clearly.

Develop and maintain financial and operational reports, including productivity, ad hoc projects, and/or KPIs, by directors and managers to improve processes and keep a pulse on daily operations.

Develop and automate Profit and loss (P&L) statements for each cost center by account for comparison and reconciliation of the budget with the general ledger. Assist department operational leaders with monitoring the applicable budget.

Provide routine updates on SPS business, including financials and metrics, to various Committees as required.

Monitor TPA data feeds for reconciliation of revenue and expense across payors and providers.

Risk & Audit Management: Identify, investigate, and resolve escalated issues and cases related to complex reimbursement.

Identify significant pharmacy audit discrepancies, exercising independent judgment and strategic decision-making to appeal and drive favorable final audit results effectively.

Analyze internal processes, technical system issues, data feed issues, and payer processing/system issues and determine/communicate corrective actions in order to resolve payment variances.

Track, document, and report audit findings and trends regularly, providing comprehensive updates to pharmacy management and identifying training opportunities or process improvements.

Responsible for acquiring knowledge of industry audit trends and compliance requirements.

Engage in coordinating and delivering assigned audits, providing invaluable support to cross-functional leadership throughout the entire audit lifecycle, from initiation to closure, including the appeals process.

Troubleshoot and resolve billing rejections and subsequently rebill claims to the appropriate carriers for all commercial, federal, and state insurance plans. Submit prior authorization requests, follow up on submitted prior authorization requests, and submit claims with approvals as appropriate.

Contact payers for lost medication overrides, replacement, and override approvals.

Act as the point of contact for all audit-related communication with contractors, ensuring seamless exchange of audit requests, results, and appeals.

Utilize databases and established frameworks to monitor compliance in documentation and coding, while proficiently managing electronic documents for project tracking and outcomes evaluation

Assist with prescription audits.

Program Administration: Develop, implement, and monitor program to increase Specialty Pharmacy Services capture rate.

Perform analyses and reports required for URAC, ACHC, and other SPS accreditations as required. Assist with accreditation submissions as they pertain to SPS evaluation and reporting.

Identify new SP opportunities based on current restricted payer networks, current limited distribution drugs, pipeline SP drugs, and all other SP opportunities.

Identify areas for process improvement and assist with executing plans to improve operational efficiencies.

Work with payers and manufacturers to gain access to limited distribution drugs and payer networks.

Interact responsively and productively with purchasing, materials handling, and other departments to promote efficient systems interface and problem resolution related to the fiscal and clinical management of specialty pharmacy programs.

Provide education on pipeline and new specialty drugs to members of the Specialty Pharmacy team.

Prepare and/or review internal reports for assigned therapy and manufacturer as requested.

Responsible for maintaining good working relationships with internal and external partners.

Serve as a subject matter expert, offering insights, solutions, and research opportunities, leveraging technology and established processes to ensure compliance and efficient payment integrity.

Document appeals of payment variances and reimbursement amounts recovered through the various appeals processes.

Interact with payers, insurance companies, pharmaceutical manufacturers, managed care, payer clearance, and other stakeholders to establish and maintain relationships that will grow and sustain the business.

Identify research or demonstration grant opportunities for Specialty Pharmacy. Prepare the grant applications and lead or participate in the research or demonstration project if the grant is awarded.

Identify patients who may qualify for patient medication assistance programs or copay assistance.

Provide concise and accurate patient status information from the system and/or, via collaboration with other team members, to assigned manufacturers.

Establish and maintain good working relationships with billing operations specialists and Outpatient Clinic pharmacy staff to maintain effective communication regarding third-party billing issues.

Assist in developing, implementing, and evaluating third-party billing policies and procedures. Educate pharmacy staff about third-party billing policies and procedures as needed.

Provide expert 340B assistance, including proactive implementation of action plans to correct compliance deficiencies; audit prevention tips; audit preparation guidance and support; recommend the means of obtaining, analyzing, and evaluating the evidentiary data to support the appeal of discrepant claims and assist with coordination of any corrective action(s) needed.

Liaise professionally and discreetly with Operations and other business unit leaders, effectively communicating significant site-level errors and issues.

Coordinate with Financial Services to review underpayments or denials, and to assure charges are handled correctly.

Assist in the development of client presentations and deliverables.

Assist with project management activities such as issue and action documentation and status reporting.

Remain current by participating in departmental continuing education, reading professional literature, and/or attending professional continuing education conferences and professional meetings.

Participate in the education of nursing staff, medical staff, and all members of the health care team.

Engage in external collaborative organizations such as Acentrus, Asembia, National Association of Specialty Pharmacy.

Attend and actively participate in Departmental and Team meetings.

Organizational Accountabilities

Organizational Accountabilities (Staff)

Organizational Commitment/Identification Anticipate and respond to customer needs; follow up until needs are met

Teamwork/Communication Demonstrate collaborative and respectful behavior

Partner with all team members to achieve goals

Receptive to others' ideas and opinions

Performance Improvement/Problem-solving Contribute to a positive work environment

Demonstrate flexibility and willingness to change

Identify opportunities to improve clinical and administrative processes

Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility Use resources efficiently

Search for less costly ways of doing things

Safety Speak up when team members appear to exhibit unsafe behavior or performance

Continuously validate and verify information needed for decision-making or documentation

Stop in the face of uncertainty and take time to resolve the situation

Demonstrate accurate, clear, and timely verbal and written communication

Actively promote safety for patients, families, visitors, and co-workers

Attend carefully to important details - practicing Stop, Think, Act, and Review in order to self-check behavior and performance

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