Pharmacy Quality Analyst (Open to hiring at Sr level)

About the position Use your strengths at Wellmark as a Pharmacy Quality Analyst! In this newly created role, you will serve as a quality assurance partner within the Pharmacy team, driving excellence across PBM and internal pharmacy operations. You will conduct complex quality reviews to ensure accuracy, consistency, and compliance with established standards, while championing enterprise-wide continuous improvement initiatives. Acting as a trusted liaison between internal stakeholders and the PBM, you will lead root cause analyses and leverage reporting and analytics to enable data-driven decision-making. Recognized as a subject matter expert and coach, you will provide consultative guidance and support to cross-functional projects aimed at optimizing pharmacy operations, reducing risk and enhancing member experience. Success in this critical role requires a unique blend of skills and experience. The ability to work independently is essential, as you will often navigate complex quality reviews and data with minimal oversight. Proactiveness and strong time management skills are key. Critical thinking is essential in this position, enabling the identification of trends and development of actionable solutions that drive operational improvements. Strong relationship management and collaboration skills are key for partnering effectively with internal teams and PBM stakeholders, ensuring alignment and shared goals. Clear and concise communication, both written and verbal, is vital for translating technical findings into meaningful insights. In addition, curiosity and an inquisitive mindset fuel continuous learning and innovation within our pharmacy department to ensure we are making health care better for our members year-over-year. This position will work a hybrid schedule of at least 3 days (Tues-Thurs) in Wellmark’s Des Moines office with 2 days remote option (Mon/Fri).

Responsibilities

• Lead assigned quality reviews of complex PBM configurations and internal pharmacy operations, ensuring alignment with Wellmark standards and regulatory requirements (e.g., validating coding accuracy across formulary, benefits, network, and prior authorization setups).
• Conduct root cause analysis of quality issues and recommend actionable improvements. Collaborate with internal teams to implement enhancements that improve operational efficiency and member outcomes.
• Collaborate with internal stakeholders and/or vendor subject matter experts on quality issues identified, ensuring timely remediation and documentation.
• Develop and maintain reporting utilizing Excel and potentially PowerBI to monitor quality trends and performance metrics. Analyze data to identify risks, opportunities, and the impact of quality initiatives. Present findings to leadership.
• Provide guidance and training to team members and stakeholders on pharmacy quality standards and processes. Represent the pharmacy team in enterprise-wide quality and compliance initiatives.
• Provide back-up assistance in cross-functional projects and testing efforts related to benefit design and system enhancements. Support the development of test plans and documentation for unique or complex configurations.
• Assist in the development and delivery of communications related to quality findings and PBM updates. Ensure messaging is clear, accurate, and aligned with Wellmark's customer experience principles.
• Maintain accurate records of quality reviews, coding validations, and issue resolutions. Ensure adherence to NCQA, CMS and internal compliance standards.
• Other duties as assigned.

Requirements

• Must have: Associate degree or direct and applicable work experience.
• Minimum of 2 years of related pharmacy operations work experience from within managed care, health care, pharmacy, PBM, customer service or similar environment. Experience should reflect knowledge of pharmacy practice (e.g., drug name, NDC, GPI), pharmacy claims processing and/or UM tools (e.g., formulary, prior authorization, step therapy).
• Experience with systems analysis or testing to include writing and executing test cases.
• Knowledge of drug coding and concepts (e.g. NDC, GPI, J codes, MediSpan, etc.).
• Ability to perform, document, and or guide others through a series of related steps and takes action to improve existing conditions and processes
• Ability to identify issues or inconsistencies; obtains relevant information, relates and compares data from different sources and identifies alternative solutions
• Knowledge of applicable regulatory standards
• Effective critical thinking and analysis skills. Ability to evaluate information and implement appropriate solutions.
• Demonstrated strong written and verbal communications skills with the ability to clearly and concisely communicate complex concepts with internal and external stakeholders.
• Strong interpersonal skills with the ability to build relationships of collaboration and trust with different business areas.
• Viewed as a subject mat

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