We are recruiting for a motivated Pharmacy and Quality Performance Analyst - Denver Health Medical Plan (Must Be A Colorado Resident) to join our team!
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Department
Managed Care Administration
- Must Be A Colorado Resident
Job Summary
The Pharmacy Business and Quality Performance Analyst drives data-informed strategies to optimize pharmacy utilization, improve care quality, and promote cost-effectiveness across Medicare, Medicaid, and Exchange lines of business. Within a provider-owned health plan, this role combines pharmacy operations and cost containment, performance analytics, and budget oversight to support Pharmacy, Quality Improvement, and Population Health departments. The analyst provides expert technical assistance to highly visible, sensitive, and multifaceted initiatives, ensuring alignment with regulatory standards while advancing value-based care through actionable insights and collaborative program development.
Essential Functions :
Pharmacy Analytics & Cost ContainmentAnalyze pharmacy and medical pharmacy claims and utilization trends to identify cost drivers, adherence gaps, and savings opportunitiesDevelop and maintain reporting tools to measure the financial and clinical impact (ROI) of utilization management strategies, including prior authorization, step therapy, and formulary design; reports are shared with departmental leaders and presented to executive stakeholdersCompile and reconcile pharmacy-related data submissions to CMS, HPMS, and State agencies-including attestations, financial reports, and encounter data-to ensure accuracy and alignment with regulatory and organizational goalsCreate monitoring reports and dashboards to evaluate pharmacy program performance and identify opportunities for improvement across utilization, cost containment, and compliance initiativesDevelop and maintain pharmacy reporting processes, policies, and procedures in alignment with State and Federal requirements or internal quality and reporting standards; ensure operationalization through documentation, workflow integration, and audit-ready reporting; proactively identify compliance gaps or performance issues and collaborate cross-functionally to implement data-driven solutionsSupport prescriber incentive programs to align clinical behavior with formulary and affordability goalsPartner with PBMs and finance teams to develop cost containment models and optimize rebate strategiesEnsure compliance with CMS, State Medicaid, ACA Exchange, NCPDP, and NCQA pharmacy-related requirements(60%)
Quality Improvement & Population HealthBuild and maintain robust reporting systems to monitor performance across HEDIS, CAHPS, and CMS MCR Star Ratings, including outreach reporting to track member engagement, intervention effectiveness, and closure of care gapsAnalyze quality trends and identify performance improvement and cost saving opportunities across government-sponsored populationsEvaluate gaps in care and support clinical interventions for chronic disease, preventive services, and medication adherenceSupport health equity initiatives through reporting and analytics, including stratification of quality metrics and identification of disparities across populationsCollaborate with Health Outcomes & Pharmacy leaders in QI and Population Health to improve performance under value-based contractsAssist with regulatory submissions, audit support, and accreditation readiness (e.g., NCQA)Support the evaluation of clinical and operational Performance Improvement Projects (PIPs), including tracking and assessing outcomes.Contribute data analysis and documentation support for Quality Assurance and Process Improvement (QAPI), and reporting for state and federal quality requirements.Analyze member experience and satisfaction trends to support quality interventions.Support Quality Committees with the preparation of data summaries and presentations.(25%)
Business, Budget & Operational AnalysisMonitor external vendors , analyzing data to ensure compliance with contractual requirements and performance expectationsConduct cost-benefit analyses and ROI evaluations for pharmacy and quality-related initiativesTranslate complex analytics into insights and visualizations for operational and executive decision-makingSupport business case development and strategic planning across Medicare, Medicaid, and ACA Exchange linesSupport the management of departmental budgets, including forecasting, tracking expenditures, and analyzing financial varianceCollaborate with actuarial, finance, and clinical teams on pharmacy and quality performance monitoring(15%)
Education :
Bachelor's degree in Pharmacy, Public Health, Health Administration, Business, Business Analysis, Health Informatics, Data Science, Epidemiology, Healthcare Economics, Nursing, or a related field requiredWork Experience :
4-6 years healthcare analytics, pharmacy services, quality improvement, or managed care operations requiredLicenses :
Knowledge, Skills and Abilities :
Knowledge of formulary management, utilization management, CMS Star Ratings, Medicaid quality metrics, and value-based care models, with demonstrated experience building reporting aligned to HEDIS and Star measure specification(s)Proficient in analytics tools such as SQL, Excel, Tableau, or Power BIFamiliarity with NCQA standards, NCPDP requirements, and actuarial or finance collaboration within managed careAbility to develop data requirements , extract, organize, analyze, interpret and communicate opportunities while working with operations teams and groupsAbility to identify and define problems based on the collection of data, establish facts and draw valid conclusions to present solutions.Demonstrates ability to manage multifaceted projects in conjunction with day-to-day activities.Excellent interpersonal and customer service skills, ability to work collaboratively with other groups (such as Compliance Department, product teams, Finance, Med-Econ, and Information Systems), external vendors and State and Federal entities.Self-motivated and takes initiative : identifies, acts on, and documents solutions for gaps and opportunities for process improvementsCritical thinking, strong written and verbal communication skills, and the ability to effectively interact within a team.Proven ability to interpret and synthesize Federal and State regulatory requirements, ensuring policies, procedures and processes are updated to comply with guidelines.Assists in monitoring of risk assessments, preparation and compilation of audit requirements interprets audit results; monitors daily, weekly and monthly reports.Knowledge of PC applications, specifically Microsoft Office products, and the ability to learn to computer applications involving Health Plan Management Software involving Claims, Enrollment systems, and Government Data Portals.Shift
Days (United States of America)
Work Type
Regular
Salary
$89,900.00 - $140,000.00 / yr
Benefits
Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans
Free RTD EcoPass (public transportation)
On-site employee fitness center and wellness classes
Childcare discount programs & exclusive perks on large brands, travel, and more
Tuition reimbursement & assistance
Education & development opportunities including career pathways and coaching
Professional clinical advancement program & shared governance
Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer
Our Values
Respect
Belonging
Accountability
Transparency
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.
As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.
Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.
Applicants will be considered until the position is filled.
