Principal PBM Operations Analyst

About Blue Cross and Blue Shield of Minnesota At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us. The Impact You Will Have The Principal PBM Operations Analyst will focus on establishing and refining operational processes related to CMS and State requirements for Medicare products. This position will develop an oversight structure of the Pharmacy Benefit Manager(s) (PBM) , departmental and key stakeholder activities. This oversight structure will include the establishment of KPI's and program dashboards to measure performance. Your Responsibilities Core responsibilities will involve project management, operational management and oversight of the Pharmacy Benefit Manager(s) (PBM). Build and manage dashboards for PBM oversight reporting including volume trending/analysis and quality review outcomes of key performance indicators including claims, coverage decisions and appeals, formulary, and networks. Present dashboards/reporting to Compliance Officer and Leadership, as applicable. Continuously assess risk and evaluate oversight program for improvement opportunities. Define and document oversight processes, policies, and procedures for delegated pharmacy functions including those intended to identify risk and internal controls. Develop enhancement strategies to existing process and technology capabilities. Manage enhancement-related projects with cross-functional teams including IT, Pharmacy, Operations, Compliance, etc. Develop and manage project plans for PBM, internal stakeholder, or external vendor initiatives to ensure an accurate, timely and highly coordinated implementation. Oversee PBM and Pharmacy Analyst work of Medicare PBM operational components. Manage, and oversee Medicare Part D requirements and corresponding operational processes. Including, but not limited to: payment integrity - PDE/Encounter Data, FIR's, NX Transactions, and Coordination of Benefits, regulatory – implementation of guidance, audit management, regulatory reporting, CMS and DHS interactions, coverage decisions and appeals, claims. benefits, formulary/PDL, networks and materials Establish PBM KPIs and Program dashboards to manage and measure outcomes related to performance guarantees. Draft and maintain administrative pharmacy policies related to core job responsibilities. Collaboratively work with internal and external partners, clients, and vendors. Oversee intake, management, and resolution of inquiries, issues, or requests for information received from members, groups, Clients, CMS/DHS and/or any other channel. This position does not have direct supervisory responsibilities but will oversee Analyst work product. Required Skills and Experience 10+ years of professional experience in pharmacy at a health plan or PBM. 7+ years of project management/relationship management experience required, preferably in the pharmacy or healthcare industry preferred. 5+ years of experience in triaging and resolving inquiries associated to claims and benefits. 7+ years of experience working Medicare Part D 5+ years of management experience (employees and/or vendor services) High school diploma (or equivalency) and legal authorization to work in the U.S. Preferred Skills and Experience Previous experience in pharmacy technician role, with or without certification PBM experience preferred Bachelor’s degree or equivalent experience Role Designation Hybrid Anchored in Connection Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week – most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships, creativity, and alignment. The rest of the week you are empowered to work remote. Compensation and Benefits $102,400.00 - $138,300.00 - $174,200.00 Annual Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job. We offer a comprehensive benefits package which may include: Medical, dental, and vision insurance Life insurance 401k Paid Time Off (PTO) Volunteer Paid Time Off (VPTO) And more To discover more about what we have to offer, please review our benefits page . Equal Employment Opportunity Statement At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affirmative Action plan, as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to, and will not be discriminated against based on any legally protected characteristic. Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: [email protected]. Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.