Prescription Plan Design Escalations Analyst I-II (...

Pharmacy Benefit Management Specialist Responsible for internal and external functions that support accurate claim processing for medications. Qualifications Required Work Experience Experience in pharmacy or medical field Experience in prescription benefit administration Experience working in vendor applications (rebate, web tools, formulary tools) 5 years' experience in progressive responsibility with allocation of resources and participating in management of complex projects (Level 4) Required Education High-School Diploma or GED Required Licenses N/A Required Certifications N/A Preferred Qualifications Preferred Work Experience Experience with a pharmacy benefit management or prescription claim administration Experience with the current BCBSAZ PBM system Experience with BCBSAZ claims software / systems Demonstrated experience handling confidential information Demonstrated experience handling vendor system coding and analytic functions 5 years' demonstrated experience handling complex projects and allocation of resources (Level 4) Preferred Education Associate's degree in general field of study Preferred Licenses N/A Preferred Certifications N/A Essential Job Functions and Responsibilities Level 1 Performs Job Functions Under Close Supervision Or Peer Review Analyze PBM prescription claim and other applicable systems for medication benefit quality and accuracy Support internal and external customers with information on benefits applicable to medication claims Perform, evaluate, and assist in defining and improving the quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines. Administer, interpret, and maintain current working knowledge of required BCBSAZ systems, procedures, forms and manuals Communicate recommendations in regard to medication claim processing and benefit decisions. Monitor and investigate reported plan set up system issues Participates in quality initiatives; including functions that support audits, reporting, evaluation of quality opportunities and concerns, and creation and implementation of corrective actions as requested. Resolve escalated member issues Research & provide recommendations for accumulations issues Logs all benefit setup issues on error tracking reports Provide monthly updates on error resolutions and impact reports Level 2 Performs Job Functions With Minimal Supervision Communicates issues identified within vendor system effectively to team. Communicates issues identified within plan setup testing or another escalated research to team Strategizes solutions for issue resolution and communicates plans to team. Provides written documentation for desk levels. Provides support to other team members when necessary Review plan testing documents for minimal accuracy Level 3 Performs Job Functions With Minimal Supervision, Acts As Subject Matter Expert Primary liaison for Pharmacy Management for applicable benefit design questions Primary SME contact for various internal departments within BCBSAZ In regard to pharmacy plan setup and design Builds reporting and analyzes data for benefit recommendations to management. Review and determine pharmacy benefit setup upon renewal for all benefit plans Build and setup all new pharmacy benefits in the pharmacy system; including standard patient pays Submit drug code assignments to enrollment for all benefit plans Maintain pharmacy drug code matrix Level 4 Lead Performs Job Functions As Assigned And Allocates Resources And Project Prioritization Perform quality checks and analysis on drug code setup from other analysts Review escalated plan testing questions for accuracy and make corrections as needed Setup all complex pharmacy benefit plan designs Setup all complex patient pays, and any other design element related to complex pharmacy benefits Works with Pharmacy Management Leadership team to identify project prioritization Allocates resources to ensure required work is accomplished within defined time frames Assigns Tasks to Analysts and Specialists as needed All Levels Each progressive level includes the ability to perform the essential functions of any lower levels and mentor employees in those levels. Properly track all pharmacy benefit issues & concerns The position has an onsite expectation of 1 day per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned. Required Competencies Required Job Skills Intermediate PC proficiency with word processing, spreadsheets, and claims and imaging software (Level 1) Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones (all Levels) Advanced PC proficiency, including spreadsheet and vendor application software (Levels 2 and 3) Required Professional Competencies Take initiative Establish and maintain working relationships in a collaborative team environment Flexibility in prioritization of workflow Compose a variety of business correspondence Required Leadership Experience and Competencies Make use of employees' skills and abilities to deliver business objectives Use available information to focus the team's activities and identify priorities Preferred Competencies Preferred Job Skills Advanced PC proficiency with word processing, spreadsheets, and claims and imaging software (Levels 2 3) Preferred Professional Competencies Effective interpersonal communication Multicultural sensitivity Claim system experience with pharmacy vendor software and/or systems (Levels 2 3) Preferred Leadership Experience and Competencies N/A Our Commitment

Created: 2026-03-04