PDE Specialist

GENERAL DESCRIPTION: Responsible for evaluating Medicare Part D pharmacy claims and their financial impact submitted by the Pharmacy Benefit Manager (PBM) of Prescription Drug Events (PDE), assuring accuracy with the Centers for Medicare and Medicaid Services (CMS) guidelines for all of the company's business lines. ESSENTIAL FUNCTIONS: • Supports readiness activities and oversees implementation testing processes to ensure program integrity and accurate deployment of CMS Part D rules and guidance, mitigating regulatory and compliance risks. • Supports internal and external regulatory audits, ensuring data integrity, timely responses to audit findings, and implementation of corrective actions in compliance with CMS and internal standards. • Serves as the primary liaison between all of the company's business lines and the PBM for all PDE-related inquiries and issue resolution, coordinating cross‑organizational communication and problem-solving. • Verifies and reconciles PDE data submitted by the PBM to ensure completeness, accuracy, and full compliance with CMS requirements. • Maintains and reconciles the PDE Audit Trail Log, ensuring ongoing compliance with CMS regulations and internal documentation standards. • Collaborates cross‑functionally with other departments to ensure proper PDE layout configuration and the accurate, timely upload of PDE files into the database of all of the company’s business lines. • Identifies trends, flags, and discrepancies in PDE and claims data, coordinating corrections with PBM, Eligibility, and other departments to resolve data integrity and reporting issues. • Identifies and resolves discrepancies between internal data and PBM-generated reports, ensuring alignment across systems and consistency in reporting and compliance. • Generates and analyzes Pharmacy vs. PDE claims reconciliation reports, including accepted, rejected, and informational claims, to support financial accuracy and regulatory compliance. • Supports the Senior Specialist in the development of PDE vs. claims reconciliation reports, identifying discrepancies that may impact financial projections or compliance outcomes. • Collaborates with internal departments to support financial analysis, forecasting, and risk assessment related to PDE claims, contributing to proactive decision-making. • Monitors PDE performance metrics to support CMS Star Ratings and internal key performance indicators (KPIs). • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: B achelor's Degree, preferably in Statistics, Mathematics, or Accounting. At least two (2) years of experience performing data analysis, financial analysis, and preparing statistical reports and metrics, preferably in the Healthcare Insurance Industry. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: Not required. Other: Knowledge and experience of the following systems is preferred : Power BI (Desktop) and advanced Excel. Knowledge of Medicare Part D regulations, PDE submission processes, and CMS audit protocols is preferred. Languages: Spanish – Intermediate (comprehensive, writing, and verbal) English – Intermediate (comprehensive, writing, and verbal)