Pharmacy Quality Analyst

Prominence Health; Reno (NV); On-site; USD 95,000 - 135,000; Full time

Benefits offered by this job

Loan Forgiveness Program

401(K) with company match

Stock plan

SoFi student loan refinancing program

Career development opportunities

Job summary

Prominence Health, part of the UHS family, seeks a Pharmacy Quality Analyst to monitor and improve operational performance across the health plan and its PBM partner. You will audit, analyze, and identify compliance risks, service gaps, and process inefficiencies affecting members, providers, and pharmacies.

You will use data analysis, CMS compliance reviews, and root cause approaches to drive corrective actions and ongoing regulatory alignment with CMS, Medicare Advantage, and contractual

Qualifications

• Bachelor’s degree in healthcare administration, Pharmacy, Business Administration, Public Health, Compliance, Data Analytics, or related field.
• 3+ years of operational experience in a retail or hospital pharmacy, PBM, managed care, or related healthcare organization.
• Knowledge of CMS Part D regulations, Medicare Advantage requirements, and audit methodologies.
• Working understanding of PBM operations, pharmacy claims adjudication, prior authorization processes, formulary administration, and member service operations.
• Proficient computer skills: HPMS, Smartsheet, SharePoint, Microsoft Office (Word, Excel, PowerPoint), and database software.
• Demonstrated ability to apply knowledge to recognize problems and initiate investigations; adhere to internal audit standards and confidentiality.

Responsibilities

• Monitor and analyze pharmacy-related operational performance across Prominence Health and its PBM partner.
• Identify operational breakdowns, compliance risks, service gaps, and process inefficiencies.
• Perform CMS compliance reviews, performance monitoring, and root-cause analyses to identify trends and corrective actions.
• Support excellence by ensuring pharmacy services, claims processing, prior authorization, formulary administration, and customer service meet CMS/Medicare Advantage and contractual requirements.

Skills

CMS Part D regulations

Medicare Advantage knowledge

Audit methodologies

PBM operations

Claims adjudication

Formulary administration

Customer service operations

Data analysis

Regulatory research

Communication skills

Education

Bachelor's degree in healthcare administration / Pharmacy / Business Administration / Public Health / Compliance / Data Analytics (or related field)

Tools

HPMS

Smartsheet

SharePoint

Microsoft Office

Job description

Responsibilities

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

Learn more at: https://prominence-health.com/

Job Summary

Under the direction of the VP of Health Services, the Pharmacy Quality Analyst is responsible for monitoring, analyzing, auditing, and improving pharmacy-related operational performance across Prominence Health and its Pharmacy Benefit Manager (PBM) partner. This position serves as a key resource for identifying operational breakdowns, compliance risks, service gaps, and process inefficiencies that impact members, providers, pharmacies and brokers. The Pharmacy Quality Analyst utilizes data analysis, operational audits, CMS compliance reviews, performance monitoring, and root cause methodologies to identify trends, investigate issues, and recommend sustainable corrective actions. The role supports operational excellence by ensuring pharmacy services, claim processing, prior authorization functions, formulary administration, customer service, and other PBM-related activities are delivered accurately, efficiently, and in compliance with CMS, Medicare Advantage, and contractual requirements. This position works closely with Pharmacy, Operations, Health Services, Compliance, Customer Service, and PBM partners to support continuous improvement initiatives that enhance regulatory compliance, operational effectiveness, and overall customer experience.

Benefit Highlights

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries!
• More information is available on our Benefits Guest Website: benefits.uhsguest.com

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

Qualifications

• Bachelor’s degree in healthcare administration, Pharmacy, Business Administration, Public Health, Complaince, Data Analytics, or related field.
• Current and valid state licensure as a pharmacy technician is preferred.
• 3 or more years of operational experience in a retail or hospital pharmacy, PBM, managed care, or related healthcare organization
• Knowledge of CMS Part D regulations, Medicare Advantage requirements, and audit methodologies
• Working understanding of PBM operations, pharmacy claims adjudication, prior authorization processes, formulary administration, and member service operations.
• Proficient computer skills: Health Plan Management System (HPMS), Smartsheet, Sharepoint, Microsoft Office (Word, Excel, PowerPoint), and database software.
• Demonstrated ability to apply knowledge to recognize the existence of problems or potential problems and identify additional research to be undertaken or assistance in the following areas: internal audit standards, procedures and techniques, management principles and deviations from ethical business practices, and fundamentals of business management.
• Demonstrated ability to research, analyze and interpret state/federal regulations related to health insurance and healthcare.
• Demonstrated ability to design and develop reports, documents and spreadsheets.
• Demonstrated ability to communicate verbally and with technical writing in a way that effectively conveys project background, objectives, activities, evaluations, conclusions, and recommendations.
• Decisive and exercises good judgment under pressure.
• Demonstrated skills in critical thinking, problem solving, and the analysis, interpretation and evaluation of complex information.
• Demonstrated ability to maintain effective collaborative working relationships with staff.
• Demonstrated ability to work independently with minimal supervision.
• Resourceful, detail-oriented, and able to assimilate and analyze a wide variety of information, often working under deadline pressure with a variety of levels of staff.
• Simultaneous action at varying stages—initiation, follow through, and completion—on a number of different projects.
• Strict adherence of rules and regulations for confidentiality and compliance.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.