Pharmacy Quality & Compliance 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

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