MedImpact Healthcare Systems, Inc.
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PDE Analyst II
at MedImpact Healthcare Systems, Inc.
San Diego, CA
# of openings:
Added to system:
12/10/18 11:05 AM
PDE Analyst II
If you’re interested in a career within a customer-focused, team-oriented environment that rewards innovation, quality, integrity and collaboration, MedImpact Healthcare Systems, Inc. welcomes your application. MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.
The PDE Analyst II is responsible for the analysis, calculation, and validation of the Medicare Prescription Drug Event (PDE) files for MedImpact’s clients. This position serves as a subject matter expert for Medicare prescription drug adjudication data and interfaces with MedImpact clients and internal staff to ensure timely and accurate PDE file submissions. This role utilizes available resources to solve mission critical problems and makes timely and effective decisions. The PDE Analyst II requires technically complex analytical skills and a high degree of accuracy, carrying with it significant consequence for the organization and MedImpact’s clients should errors occur.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
- Understands the PDE edit resolution process as well as roles and responsibilities across the organization in order to support edit resolutions. Analyzes and reconciles PDE entries rejected by CMS, including rejections related to eligibility and PDE calculations. Analyzes trends in rejected records and clearly conveys issues to clients along with recommendations for resolution.
- Manages PDE file generation process from end to end. These duties include cycle generation, executing PDE load and extract programs, file quality control, file submission to CMS or clients. Independently executes the retrieval and processing of CMS response files, providing detailed analysis of file results. Provides concise feedback to clients on file outcomes and edit resolution.
- Understands PDE reporting requirements including PDE file layout and the DDPS response file layout in order to manage associated data fields and basic PDE calculations for all plan types and mapping rules.
- Maintains current understanding of assigned client's Medicare Part D coverage and benefit plans in order to analyze the accuracy of PDE records. Monitors claim activities to ensure inclusion of all appropriate claim records, adjustments and deletions of the data prior to submission.
- Establishes positive working relationships with internal and external clients by providing sustainable, measurable, accurate, reliable and timely execution of PDE data responsibilities. Supports the corporate strategy by delivering solution-oriented problem solving techniques.
- Utilizes multiple company databases to obtain, record, and analyze complex claim information.
- Participates in interdepartmental meetings and client conference calls as the subject matter expert regarding Medicare Part D PDE data.
- Requires limited assistance or supervision to amend queries to extract specific data to meet the requirements of daily job functions.
- Executes established SQL queries, extracting data from relational data bases and tables for purposes of edit resolution, audit support, issue identification and the generation of impact analysis for clients.
- Ensures continuous improvement of Medicare claims data; conducting root cause analysis of errors, making recommendations for systems and procedure enhancements, and providing education and training as appropriate. Makes recommendations to department leadership for improvement in workflow processes to support timely and accurate PDE submissions.
- Participates in implementation meetings to facilitate onboarding of new MedImpact clients. Providing technical information and education about PDE processing to ensure new clients achieve high success during their first year experience.
- Mentors and trains less experienced PDE Analysts and other employees within the GPS department.
Education and/or Experience
Associates degree from an accredited institution (or equivalent combination of education and experience) along with five (5) plus years’ related experience in healthcare industry or in the regulatory field. Must have two (2) plus years’ experience analyzing data, determining trends and doing comparative analysis. Highly desire Medicare program knowledge and PBM industry experience.
Intermediate level of expertise with MS Excel, MS Word and Outlook tools. Basic knowledge of Oracle/SQL queries preferred. Experience with Golden 32 a plus. Good working knowledge of proprietary healthcare operating systems desired.
Other Skills and Abilities
- Detailed understanding of claim processing concepts.
- Intermediate level of expertise of both Oracle/SQL and Golden 32
- Ability to prioritize urgent issues effectively.
- Outstanding numeric, verbal, written, logic and analytical skills.
- Knowledge of healthcare operating systems preferred.
- Detail oriented with a high degree of accuracy & follow through.
- Self-starter with the ability to work independently & as part of a team.
- Ability to influence others, lead small work groups, and coordinate service requests throughout the organization.
To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.