HealthPartners is hiring a Pharmacy UM Compliance and Operations Analyst. This position works with pharmacy leaders to develop and implement monitoring tools that ensure compliance, performance standards and audit readiness. The position provides timely and effective feedback and ensures quality of departmental prior authorization and exception reviews via case auditing. This position ensures a collaborative and integrated approach to utilization management processes and quality. This position will also serve as a subject matter expert for pharmacy utilization management applications, including working as a liaison between the business and IT teams. This position provides support and coordination for the pharmacy utilization management team in maintaining a constant state of readiness for and compliance with regulatory and accreditation requirements. MINIMUM QUALIFICATIONS:
| Education, Experience or Equivalent Combination: |
Bachelor's Degree or equivalent experience Three years' experience in managed care pharmacy, program compliance, utilization review and utilization management |
| Licensure/ Registration/ Certification: |
|
| Knowledge, Skills, and Abilities: |
Knowledge of quality standards and regulations Demonstrated comprehensive, in-depth knowledge, of corporate compliance requirements Ability to plan, organize, and prioritize work effectively, including the flexibility to accommodate frequent changes Expertise in working collaboratively and communicating with staff in different positions and all levels of management positions Strong analytical and problem-solving skills related to software system-based processes Working knowledge of various reporting tools and strategies Ability to deal with ambiguity and changing priorities High degree of initiative and ability to work independently and within a group Excellent written and oral communication skills, including facilitation and presentation skills in technical and non-technical vernacular Excellent computer skills including Microsoft Word, Outlook, Power Point and Excel Excellent technical and business writing and editing skills with a focus on policy and procedure writing Effective work history with range of internal and external customers Excellent follow through and problem-solving skills and attention to detail Ability to work independently and as part of a team |
PREFERRED QUALIFICATIONS:
| Education, Experience or Equivalent Combination: |
Previous experience in HealthPartners Pharmacy Administration and pharmacy UM reviews Direct work experience with government programs and regulatory matters Experience working with a utilization software program Experience working with Compliance 360 monitoring tool |
| Licensure/ Registration/ Certification: |
|
| Knowledge, Skills, and Abilities: |
Knowledge of HealthPartners Knowledge of HealthPartners systems and applications Experience with Microsoft Access |
| Essential Duties: |
% Of Time (minimum 5% increments) |
| 1. |
Support Functions for Staff Training Works closely with the other pharmacy staff to assure that training, procedures, task lists, and processes support policies, department needs, and regulatory and accreditation standards Provides training and communication on program changes to staff as appropriate Provide end user support and excellent customer service to pharmacy prior authorization staff in supporting and troubleshooting pharmacy utilization management software applications used by staff Trains Pharmacy UM Quality Specialists as needed and assigned Assist with training of Pharmacy Customer Service Assistants as needed and assigned |
20 |
| 2. |
Audit/Compliance and Reporting Monitors audit reports daily, weekly, and monthly for tracking and trending issues or risks Utilizes audit tools, to ensure compliance with Federal and State review regulations, performance standards and audit readiness are met Support regulatory compliance by routinely reviewing all government programs utilization management reporting and audit requirements, NCQA standards, and applicable state regulations Supports regulatory and accreditation audits including universe file pulls, file preparation, and submission of documentation as needed Actively participate in audits and audit-related activities as required by NCQA, MDH, CMS, or other regulatory/accreditation agency Identify and present opportunities for process improvement to increase data integrity, improve quality of reports, and ensure compliance Advises the pharmacy prior authorization leadership team of potential compliance concerns |
30 |
| 3. |
Quality Monitoring for Utilization Management Program Develops and maintains knowledge of NCQA accreditation and delegation requirements, MDH audit requirements, CMS reporting and universe requirements, and CMS guidance as it relates to pharmacy utilization management reviews Understand process changes within the department that impact letters and file review standards, and monitors for compliance with changes Responsible for accuracy of data used to monitor compliance with turnaround times, letter standards, and notification standards Develops and executes monitoring and compliance activities with project management tools and approaches Communicates progress of monitoring program and issues for resolution to pharmacy prior authorization leadership team |
20 |
| 4. |
Pharmacy Utilization Management Systems Support Assists management in the analysis, development, and design of improved automated tools and processes so that employees can more effectively perform their jobs Identify and request system enhancements, recommends priorities for requests, and develop requirements, testing, training, and implementation of application installments and upgrades Actively participates in system updates and testing of application and process changes as needed |
20 |
| 5. |
General Performance/Knowledge Willingly participates in various workgroups, committees, and projects as needed and assigned Maintains appropriate confidentiality of information in accordance with HealthPartners corporate policies Develops and maintains positive, effective working relationships with prior authorization program review and support staff as well as other internal departments and applicable system software vendors Participates in ongoing independent study and education to develop and maintain knowledge in the areas of applicable software systems, regulatory and accreditation standards, quality improvement strategies and compliance requirements Demonstrates responsiveness to and appreciation of constructive feedback and recommendations for personal growth and development |
10 |
*Job description rankings/percentages are intended to reflect normal averages over an extended period of time, and are subject to daily variances. Quality and efficiency standards should at no time be compromised to meet the average expectations expressed above. Job descriptions are subject to change to accommodate organization or department needs. MAJOR CHALLENGES: Responsible for the coordination and implementation of daily program management activities for Government Programs monitoring programs Needs to balance and manage demands of our customers (regulatory agencies, business partners with internal operational concerns, review staff) and quality and performance standards Facilitate interdepartmental compliance with program requirements Key resource for internal and external contacts on program administration Keep leadership and key partners informed of problems, concerns and trends that arise DECISION-MAKING: Manages daily work by determining priorities for multiple projects Identifies opportunities for/barriers to improvement, and communicates them to leadership for review and resolution Collaborates across multiple managers and areas for input and summation of issues and recommendations Prepares recommendations to various levels of leadership regarding conclusions and solutions to identified system issues Identifies and appropriately communicates system issues, risk, and barriers to/needs for improvement to leadership ORGANIZATIONAL EXPECTATIONS: Values All colleagues are expected to live our values: Excellence: We strive for the best results and always look for ways to improve. Compassion: We care and show empathy and respect for each person. Partnership: We are strongest when we work together and with those we serve. Integrity: We are open and honest, and we keep our commitments. Additional Expectations: Complies with safety instructions, observe safe work practices, provides input on safety issues, and promotes a safe work environment. Maintains regular and timely attendance Protects confidentiality Demonstrates participation in and support of the organization's Corporate Integrity Program by participating in compliance-related education and training and complying with the organization's policies and procedures. Timely completion of all mandatory education and organizational requirements (i.e., licensure/certification, Employee Health and Wellness requirements, annual training, etc.) |
HealthPartners
Jul 06, 2026 