Senior Business Analyst - Medicare (Hybrid)

CareFirst BlueCross BlueShield; Baltimore (MD); On-site; USD 72,828 - 146,432; Full time

Job summary

CareFirst BlueCross BlueShield is seeking a Senior Business Analyst to drive critical Medicare pharmacy programs through advanced data analysis, reporting, and operational PBM oversight.

You will interpret complex data to build reports, ensure regulatory compliance, and support quality and performance goals across pharmacy operations. This role emphasizes cross-functional coordination with leadership and vendors.

Qualifications

• Bachelor's degree in Business, IT, CS, or related field; or 4 additional years of relevant work experience.
• 5 years of progressive experience in business analysis, systems analysis, testing, or similar analytical roles.

Responsibilities

• Analyze pharmacy operational data and claims to identify trends and improvement opportunities.
• Monitor claims processing and review PBM coding for accuracy and compliance.
• Perform PDE review, correction, and retraction activities.
• Prepare and submit Medicare KPI reports including PBM performance and compliance tracking.
• Provide analytical support and recommendations to pharmacy leadership for operational decisions.

Skills

Advanced data analysis

Reporting & dashboards

Stakeholder communication

Regulatory/compliance understanding

Education

Bachelor's degree in Business/IT/CS

Alternatively 4 years relevant work experience

Job description

Purpose

The Senior Business Analyst supports critical Medicare pharmacy business through advanced data analysis, reporting, and operational PBM oversight. This role interprets complex data to develop reports and presentations, ensures compliance with contractual and regulatory requirements, and supports quality and performance objectives across pharmacy operations.

Essential Functions

Pharmacy Operational & Analytical Functions

• Analyze pharmacy operational data and claims activity to identify trends, risks, and improvement opportunities.
• Monitor claims processing and review pharmacy benefit coding for accuracy and compliance.
• Perform prescription drug event (PDE) review, correction, and retraction activities.

Medicare Regulatory & Compliance Functions

• Review and analyze monthly, quarterly, and annual data related to coverage determinations, redeterminations, and grievances.
• Track, document, and trend Medicare and PBM‑related issues to support compliance, audit readiness, and corrective action activities.
• Participate in internal and external audits and third‑party reviews, including formulary administration, improper payment, and Acumen reporting.

Reporting & Decision Support

• Prepare and submit routine and ad hoc Medicare KPI reports, including PBM performance and compliance tracking.
• Provide analytical support and recommendations to pharmacy leadership to inform operational and strategic decisions.

Communication & Stakeholder Support

• Monitor member and provider communications for accuracy, timeliness, and regulatory compliance, including letters, explanations of benefits, and website content.
• Coordinate with internal and external stakeholders to ensure PBM activities align with pharmacy operations and member experience expectations.
• Serve as a point of contact for vendor performance oversight and issue resolution.

Quality & Continuous Improvement

• Support quality initiatives through provider and member outreach, participation in committees, and support of member events.
• Conduct process analysis and contribute to studies aimed at improving efficiency, quality, and compliance.
• Adapt to shifting priorities and manage multiple concurrent initiatives, providing operational support as needed.

Qualifications

• Education Level: Bachelor's Degree in Business, Information Technology, Computer Science, or a related field.  Alternatively, in lieu of a bachelor’s degree, an additional 4 years of relevant work experience is required.
• Experience: 5 years of progressive experience in business analysis, systems analysis, testing, or other analytical roles.

Preferred Qualifications

• Demonstrated ability to deliver high‑quality, effective deliverables on time and be a significant contributor to the development of cost‑effective solutions.
• Proven understanding of business analysis core competencies.
• Certified Pharmacy Technician.
• Experience at a health plan or PBM.
• Knowledge of CMS guidance and regulations.
• Experience with pharmacy claims processing systems.

Knowledge, Skills and Abilities (KSAs)

• High level of knowledge and understanding of business products and services.
• Microsoft Office applications usage.
• Excellent communication skills, both written and verbal.
• Ability to analyze, organize, and prioritize work while meeting multiple deadlines.
• Ability to provide positive customer service and communicate effectively with internal and external customers, even in challenging situations.

Salary Range

$73,728 - $146,432

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disqualification / Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

Physical Demands

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Eligibility

Must be eligible to work in the U.S. without sponsorship.