Business Analyst

Handle first-level escalations within the Pharmacy QA team, resolving discrepancies and clarifying process concerns to ensure smooth and consistent issue resolution. Act as the point of contact during audit disagreements, guiding conversations toward resolution while keeping teams aligned with CMS guidelines and internal standards. Review drug formularies and system build-outs before CMS submission to ensure accuracy in member cost shares and regulatory compliance. Maintain and revise department SOPs, supporting policy updates with training materials that keep the QA team aligned and audit-ready. Collaborate with teams across Medicare, Medicaid, Commercial, Self-Funded, PBM, and EGWP lines of business to support shared QA initiatives. Organize weekly schedules, monitor team workload, and step into day-to-day tasks when needed, supporting operational continuity and team performance.

Evaluated rejected and paid pharmacy claims across Medicare, Medicaid, and commercial lines of business, identifying discrepancies and ensuring compliance with CMS, DOH, and DFS regulations. Reviewed eligibility data, appeals, and coverage determinations to validate processing logic and ensure members received accurate decisions and benefits. Analyzed universe data submissions before CMS audits, validating datasets and preventing systemic errors prior to final file submission. Flagged system errors that impacted member cost shares or coverage, initiating notification protocols to ensure members received timely and compliant updates. Documented quality assurance findings and delivered reports to cross-functional stakeholders, helping align compliance operations with broader organizational goals.

Verified patient eligibility and insurance coverage with precision, ensuring compliance with payer requirements and supporting accurate downstream claims processing. Reviewed and processed prior authorization requests for procedures, medications, and treatments, applying working knowledge of CPT, ICD-10, and HCPCS codes to validate medical necessity. Supported system efficiency by entering coverage overrides and communicating decisions to stakeholders, helping streamline patient access to care. Played a key role in onboarding and mentoring new team members, breaking down complex processes into clear, actionable steps that boosted early confidence and accuracy. Ensured strict HIPAA compliance while managing sensitive data, minimizing risk and reinforcing trust during critical decision-making in the authorization process.