Claims Analyst or Claims Analysis Manager, Nashville, TN

This is a new position. As Pharmacy develops as a business, we need the ability to perform in depth analysis of claims costs to identify the reasons for trend changes and variances against our forecasts. In addition, working in concert with our Medical Directors, this position will help identify cost issues which need to be brought to the attention of our markets in an actionable form. Must have 5 - 10 years experience in this role with a drug manufacturer, payer or PBM. The candidate will work closely with our data base teams, clinical teams and actuary. The candidate will have appropriate data analysis skills, reporting skills and comfortable working in Access, SQL and SAS environments. Part D experience preferred, but not required.  

The types of pharmacy related analyses include the following:

Gather known trends, symptoms and root causes

Year on year trend reports

Changes to benefit levels, formulary changes, member cost-share and other product benefit design changes

Conduct high-level disaggregation of trend into utilization (by drug) and unit cost per drug over minimum three periods (e.g. 1H06, 1H07, 1H08; to account for seasonality)

Separate measurements by region

Separate measurements of unique populations (benefit/product, duals/non-duals)

Separate channel (mail versus retail)

Specialty pharma

For high-trending drugs, conduct specific analysis, including: Channel distribution

Channel distribution

Substitution impact (utilization of high-cost drug prescribed for a condition being substituted for lower cost alternative)

Match of prior-auth data with claims

Checking for “leakage” – refill-too-soon, dosage above Rx, etc.

“Same store analysis”: track utilization (by drug, by channel; utilization and unit cost per Rx) of sample of members over the course of evaluation period

High utilizer/high change in utilization member review – check for underlying root causes/new conditions

1st year member impact

HCC coding impact (on MA-PD members)

Disease progression/aging impact

Impact of “leavers” and “joiners”: track specific populations that have left HealthSpring or joined HealthSpring during the evaluation period (utilization, unit cost); calculate incremental impact

Consolidate impact calculations and reconcile aggregate impact into overall trend; account for multiplier effects, double counting

Conduct follow-up ad-hoc analysis