Pharmacy Operations Business Analyst

Moda Health; Portland (OR); Hybrid; USD 60,000 - 75,000; Full time

Benefits offered by this job

Medical, Dental, Vision

401K Matching

FSA

Employee Assistance Program

PTO and Holidays

Job summary

Moda Health in Portland, OR is seeking a Pharmacy Operations Business Analyst to serve as the technical and analytical resource for Pharmacy Operations. You will analyze pharmacy claims, validate benefit configuration, support implementations, and develop reporting tools to improve efficiency and regulatory compliance.

You will work with Pharmacy Operations leadership, IT, account management, Compliance, and vendor partners across Commercial, Exchange, Medicare, and Medicaid lines to ensure

Qualifications

• Bachelor's degree or equivalent in health admin, business, pharmacy, information systems, or related field.
• Five+ years in pharmacy operations, PBM, health plan administration, or related healthcare.
• Knowledge of pharmacy benefit administration, claims processing, formulary management, prior authorization, and workflows.
• Experience analyzing complex data to identify issues and improve performance.
• Experience developing business requirements, testing, and system implementations.
• Knowledge of Commercial, Exchange, Medicare, and Medicaid pharmacy operations and regulatory environments.
• Strong analytical and root-cause investigation skills.
• Ability to manage multiple priorities and work independently.
• Strong written and verbal communication with stakeholders.
• Proficiency with Excel and pharmacy ops systems/reporting tools.
• Ability to develop documentation and testing docs.

Responsibilities

• Analyze pharmacy operational data to identify trends, risks, and opportunities for improvement.
• Perform root cause investigations for claims discrepancies and vendor incidents.
• Develop dashboards and monitoring tools to measure performance.
• Support regulatory compliance, CMS reporting, and audit readiness.
• Collaborate with internal teams and vendors to improve operations.
• Support client implementations and system enhancements.

Skills

Analytical thinking

Root cause analysis

Communication skills

Cross-functional collaboration

Problem-solving

Detail-oriented

Education

Bachelor's degree in healthcare administration, business administration, pharmacy, information systems, or a related field

Tools

SQL

Power BI

Tableau

Excel

Pharmacy systems

Job description

Let’s do great things, together!

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Position Summary

This is a FT hybrid position based in Portland. The Pharmacy Operations Business Analyst serves as the technical and analytical resource for Pharmacy Operations, supporting the design, validation, monitoring, and continuous improvement of pharmacy operational processes, systems, and vendor performance. The role is responsible for analyzing pharmacy claims, validating benefit and formulary configuration, supporting operational implementations, developing reporting and monitoring tools, and identifying opportunities to improve operational efficiency, accuracy, and regulatory compliance. Working closely with Pharmacy Operations leadership, Information Technology, Account Management, Compliance, vendor partners, and other business stakeholders, the Pharmacy Operations Business Analyst performs complex operational analysis, root cause investigations, data validation, configuration testing, and system support across Commercial, Exchange, Medicare, and Medicaid lines of business. The role plays a critical part in ensuring the accuracy of pharmacy benefit administration, supporting CMS reporting and audit activities, monitoring operational performance, and implementing sustainable controls that improve quality and reduce operational risk.

Pay Range

$59,922.05 - $74,902.56 annually (depending on experience).

• Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education

• Bachelor's degree or equivalent combination of education and relevant experience in healthcare administration, business administration, pharmacy, information systems, or a related field.
• Five or more years of professional experience in pharmacy operations, pharmacy benefit management, health plan administration, or a closely related healthcare environment.
• Demonstrated knowledge of pharmacy benefit administration, pharmacy claims processing, benefit configuration, formulary management, prior authorization operations, and operational workflows.
• Experience analyzing complex operational data, pharmacy claims, system functionality, and business processes to identify issues, recommend solutions, and improve operational performance.
• Experience developing business requirements, coordinating system testing, validating system enhancements, and supporting operational implementations.
• Demonstrated knowledge of Commercial, Exchange, Medicare, and Medicaid pharmacy operations and applicable regulatory environments.
• Strong analytical, problem-solving, and root cause investigation skills with the ability to interpret complex operational and claims data
• Demonstrated ability to manage multiple priorities, work independently, and successfully support concurrent operational initiatives.
• Strong written, verbal, presentation, and interpersonal communication skills, with the ability to communicate effectively with both business and technical stakeholders.
• Proficiency with Microsoft Office applications, particularly Excel, and experience working with pharmacy operational systems, reporting tools, or healthcare data platforms.
• Demonstrated ability to develop documentation, operational procedures, business requirements, and testing documentation.

Preferred Skills, Experience & Education

• Experience supporting Medicare Part D operations, CMS reporting, audit activities, or regulatory compliance initiatives.
• Experience with PBM claims adjudication platforms, pharmacy benefit configuration, formulary management systems, or prior authorization platforms.
• Experience performing pharmacy claims analysis, configuration validation, benefit testing, or operational monitoring.
• Experience developing operational reporting, dashboards, data validation processes, or performance monitoring tools using SQL, Power BI, Tableau, or comparable reporting tools.
• Experience supporting vendor oversight, system implementations, operational readiness activities, or cross-functional process improvement initiatives.
• Experience conducting root cause investigations and developing operational controls to improve quality, compliance and operational performance.

Primary Functions

Operational Analysis & Monitoring

• Analyze pharmacy claims, operational data, and system activity to identify trends, operational issues, and opportunities for improvement.
• Conduct root cause investigations for claims discrepancies, operational issues, configuration concerns, and vendor-related incidents.
• Develop operational reporting, dashboards, and monitoring tools to measure performance, identify emerging risks, and support operational decision-making.
• Perform data validation and operational monitoring to ensure the accuracy and integrity of pharmacy operations across Commercial, Exchange, Medicare, and Medicaid lines of business.

Pharmacy Systems, Configuration & Testing

• Validate pharmacy benefit, formulary, network, and prior authorization configuration to ensure accurate claims adjudication and operational performance.
• Coordinate and perform benefit, formulary, and system testing supporting new client implementations, regulatory changes, operational enhancements, and vendor releases.
• Develop business requirements, test plans, test scenarios, and validation documentation while tracking issues through resolution.
• Partner with internal stakeholders and vendor partners to evaluate system enhancements, validate implementation outcomes, and recommend operational improvements.

Medicare Operations, Compliance & Vendor Oversight

• Support Medicare Part D operational activities, including CMS reporting support, operational monitoring, audit readiness, and regulatory compliance initiatives.
• Assist with internal and external audit activities through data validation, issue analysis, documentation, and corrective action support.
• Monitor vendor operational performance, validate deliverables, investigate discrepancies, and coordinate issue resolution with vendor partners.
• Develop and maintain operational controls that improve data integrity, regulatory compliance, and vendor accountability.

Process Improvement & Cross-Functional Support

• Identify opportunities to improve pharmacy operational processes through automation, standardization, enhanced reporting, and monitoring.
• Develop and maintain business requirements, operational procedures, process documentation, reporting specifications, and technical documentation supporting pharmacy operations.
• Provide analytical support for new client implementations, operational projects, system enhancements, and strategic initiatives.
• Collaborate with Pharmacy Operations, Clinical Pharmacy, Account Management, Information Technology, Compliance, Customer Service, and vendor partners to support operational excellence and continuous improvement.

Key Responsibilities

• Analyze pharmacy operational data to identify trends, risks, and opportunities for improvement.
• Perform claims analysis, configuration validation, and root cause investigations to support operational excellence.
• Develop reporting and monitoring solutions that improve operational visibility and oversight.
• Support operational implementations through requirements gathering, testing, validation, and post-implementation analysis.
• Ensure the accuracy and integrity of pharmacy operational systems through ongoing monitoring, testing, and data validation.
• Collaborate with internal teams and vendor partners to improve operational performance and resolve complex business issues.
• Support regulatory compliance, audit readiness, and continuous process improvement initiatives.

Working Conditions & Contact With Others

• Remote, office environment, and/or hybrid with extensive close PC and keyboard work, and constant sitting. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business needs.
• Internally with Pharmacy Operations, Clinical Pharmacy, Account Management, Information Technology, Compliance, Customer Service, and other business departments and organizational leadership as required to support operational analysis, system enhancements, regulatory initiatives, and continuous process improvement.
• Externally with PBM, pharmacy technology and operational vendors, and external business partners.

Together, we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. For more information regarding accommodations please direct your questions to Kristy Nehler and Danielle Baker via our [e-mail] email.