New 
Prescription Plan Design & Escalations Analyst
 Spectraforce Technologies | |
 United States, Arizona, Phoenix | |
 Jan 02, 2026 | |
|
Position Title: Prescription Plan Design & Escalations Analyst
Work Location: Remote Assignment Duration: 12 Months 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. Position Summary: * 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. Key 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 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 SUPERVISON, ACTS AS SUBJECT MATTER EXPERT * Primary liaison for Pharmacy Management for applicable benefit design questions * Primary SME contact for various internal departments within the organization 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 * Perform all other duties as assigned. Qualification & Experience: * 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) * High-School Diploma or GED | |