Pharmacy 340B Analyst - Pharmacy- 1.0 FT - 8hrs days variable

Description

Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5

Job Description

Division: Pharmacy Department, Operations and Support Division

Job Title: Pharmacy 340B Analyst

Job Code:

Under the direction of the Director of Pharmacy, with day-to-day

Position Summary

direction from the Pharmacy 340B Program Coordinator, the Pharmacy

340B Analyst performs the data analysis, reconciliation, and reporting

that support daily operation of the 340B Drug Program. The Analyst

validates 340B accumulations, replenishment, and split-billing accuracy,

prepares compliance and savings reporting, supports internal and

external audits, and escalates identified compliance risks. This position

performs analysis and executes established processes; program policy,

vendor contracting, external commitments, and institutional compliance

authority remain with the Pharmacy 340B Program Coordinator and

pharmacy leadership.

Reports to: Director of Pharmacy (day-to-day direction from the

Pharmacy 340B Program Coordinator)

Statement of Accountability

Required Qualifications

Qualifications

• Education

1. California State Board of Pharmacy Technician Registration and

Pharmacy Technician National Certification, maintained in active

status and available for primary source verification.

2. Certification from Apexus 340B University course required within

6 months of hire; maintains current knowledge as Apexus and

HRSA guidance is updated.

3. Demonstrated ability to work accurately with large data sets in

Microsoft Excel, including pivot tables, lookup functions, and

reconciliation of data from multiple sources.

• Licensure

• Work Experience

• Skills/computer/ specific

technical

• Other qualifications,

miscellaneous

4. Completes hospital orientation, initial competency assessment,

and all required annual compliance education (including HIPAA,

workplace violence prevention, and safety) within required

timeframes.

Specify if qualifications are

required or preferred

Preferred Qualifications

5. Two (2) year degree or higher preferred.

6. One (1) year of experience in pharmacy operations, pharmacy

purchasing, revenue integrity, health system finance, or

healthcare data analysis preferred.

7. Working knowledge of 340B Drug Program requirements, split-

billing software, and contract pharmacy operations preferred.

8. Familiarity with wholesaler ordering platforms and

GPO/WAC/340B account structures preferred.

9. Critical thinking skills and the ability to identify issues, trends,

and exceptions in data and trace them to root cause.

10. Ability to organize work, meet recurring deadlines, and work

independently within established procedures in a rapidly

changing environment.

2000 Mowry Avenue

Fremont, CA 94538

510.797.1111

www.washingtonhealth.com

Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5

Essential Job Responsibilities

Achieving Results

1. Reviews daily 340B accumulation, replenishment, and order activity

in the split-billing system and resolves or escalates exceptions within

established timeframes.

2. Validates patient, provider, and location eligibility on 340B-identified

claims against the hospital’s established eligibility criteria and

documents the result of each review.

Key Components: assess,

plan, evaluate, demonstrate

initiative, quality of work,

productivity

3. Reconciles 340B purchases against accumulations to confirm that

quantities purchased are supported by qualifying dispenses, and

investigates variances to root cause.

4. Prepares recurring 340B savings, utilization, and compliance reports

for pharmacy leadership on a defined schedule.

5. Monitors contract pharmacy third-party administrator (TPA) reports

and dispensing activity and identifies discrepancies for follow-up.

6. Maintains documentation supporting each review, reconciliation, and

correction so that the program’s work is auditable.

7. Supports the Pharmacy 340B Program Coordinator in preparing

data and materials for the 340B oversight team and other

committees.

8. Escalates suspected diversion, duplicate discount, or eligibility

concerns to the Pharmacy 340B Program Coordinator and

pharmacy leadership promptly upon identification.

1. Uses the 340B split-billing software to review accumulations,

mappings, exclusions, and exception queues, and recommends

mapping corrections to the Pharmacy 340B Program Coordinator.

2. Analyzes NDC-level purchasing, dispensing, and billing data to

identify discrepancies and works with Revenue Integrity and

Pharmacy IT to research and resolve them.

3. Applies intermediate to advanced spreadsheet and data analysis

skills to reconcile purchase, dispense, and claims data drawn from

multiple systems.

Demonstrates Skill

Key Components:

competency, job knowledge,

organizational skills, analytical

skill, management of

information, employee &

patient safety

4. Supports maintenance of the hospital’s records in the 340B Office of

Pharmacy Affairs Information System (OPAIS), including preparing

child site and contract pharmacy information for review and

assembling documentation for annual recertification.

5. Executes established duplicate discount prevention procedures for

Medicaid, including applying carve-in/carve-out rules, billing

identifiers, and state-specific billing and modifier requirements,

including Medi-Cal.

6. Compiles and validates data supporting nonduplication between

340B and the Medicare Drug Price Negotiation Program, including

identifying claims for selected drugs and supporting reconciliation of

maximum fair price (MFP) refunds.

7. Prepares data sets required under manufacturer contract pharmacy

policies and, where the hospital elects to participate, for submission

to CMS or manufacturer platforms, subject to review and approval

by the Pharmacy 340B Program Coordinator.

2000 Mowry Avenue

Fremont, CA 94538

510.797.1111

www.washingtonhealth.com

Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5

8. Compares invoice pricing to published 340B ceiling prices, identifies

suspected overcharges, and prepares documentation supporting

credit or refund requests.

9. Monitors 340B inventory accumulation, replenishment, exclusions,

and shortages, and notifies the Pharmacy Buyer and Pharmacy

340B Program Coordinator when alternative products are needed.

10. Follows established standard operating procedures for the 340B

program and contract pharmacies, and recommends revisions when

a process does not work as intended.

11. Maintains working knowledge of wholesaler ordering platforms and

GPO/WAC/340B account structures and how purchasing decisions

affect program compliance.

12. Presents analysis clearly in writing and verbally, translating technical

findings into information that pharmacy, finance, and compliance

staff can act on.

13. Responds to routine requests regarding 340B data and activity,

referring policy interpretation and any external commitment to the

Pharmacy 340B Program Coordinator.

14. Maintains accuracy across multiple recurring deadlines in a

changing environment.

1. Plans and completes recurring reconciliation, reporting, and self-

audit tasks on schedule with limited supervision.

2. Performs self-audit sampling under the direction of the Pharmacy

340B Program Coordinator, covering patient and provider eligibility,

child site and contract pharmacy activity, and duplicate discount

prevention, and documents findings.

Planning & Coordinating

Key Components: delegates,

decision making, problem

solving, management of

resources

3. Assembles documentation, samples, and data extracts requested

during HRSA audits, manufacturer audits, and internal compliance

reviews.

4. Tracks corrective action items to completion and reports status to

the Pharmacy 340B Program Coordinator.

5. Coordinates with pharmacy, revenue integrity, finance, information

technology, and departmental staff to obtain the data required for

analysis.

6. Prepares audit findings, reports, graphs, and charts, and contributes

to presentations delivered to work groups and committees.

7. Prioritizes competing deadlines and escalates conflicts rather than

allowing compliance deliverables to lapse.

8. Works effectively with a variety of personnel with backgrounds

varied in education and skill sets.

9. Maintains organized, retrievable working files so that another staff

member can follow and reproduce the analysis.

10. Contributes to orientation and training of staff on 340B data

processes as requested.

1.

The Pharmacy 340B Analyst performs duties following established

work routines, constantly organizing his/her work within a

frequently busy environment.

Professionalism

Key Components:

dependability, interpersonal

skills, teamwork, patient first

ethic, customer service,

2000 Mowry Avenue

Fremont, CA 94538

510.797.1111

www.washingtonhealth.com

Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5

2.

3.

4.

The ability to constantly follow direction with high attention to detail

is critical and essential; accuracy in 340B data directly affects

program compliance and patient access to medications.

Exercises independent judgment within established procedures

and escalates matters requiring policy interpretation or decision to

the Pharmacy 340B Program Coordinator.

Must display appropriate interpersonal skills while working

productively and efficiently in a team atmosphere.

Patient confidentiality must be continuously observed.

Attention to detail and neatness is required continuously during the

everyday activities in which the Pharmacy 340B Analyst involves

his/her workday (evidenced by preciseness in task performance

and orderliness of the work area).

communication skills,

punctuality/attendance,

receptiveness to criticism,

judgment, confidentiality

5.

6.

7.

8.

Completes assigned routine work tasks while accommodating

urgent or time-sensitive requests.

Must be capable of applying new information immediately and

consistently.

9.

10.

11.

Be collaborative at all times.

Respect privacy and confidentiality at all times.

Demonstrates the values and behaviors of the organization.

1.

Identifies trends and exceptions in 340B data that indicate

opportunities for savings, improved capture, or compliance risk,

and recommends them to the Pharmacy 340B Program

Coordinator for evaluation.

Recommends refinements to reconciliation, mapping, and reporting

processes to improve accuracy and reduce manual effort.

Analyzes utilization of the split-billing system and other existing

software to identify underused functionality that would strengthen

compliance or capture.

Improving the Organization

Key Components:

performance improvement,

quality initiatives

2.

3.

4.

5.

6.

Prepares supporting data for evaluation of outpatient points of

service that may qualify for the 340B program.

Participates in departmental performance improvement activities.

Prepares and analyzes data.

Contributes 340B data, audit results, and corrective action

outcomes to the hospital’s performance improvement program (LD

12.01.01).

7.

8.

Participates in projects, councils, and special initiatives related to

340B, compliance, and medication management as assigned.

Supports implementation of approved process changes and

monitors results after implementation to confirm the intended

effect.

1.

Maintains working knowledge of 340B program rules and of

changes issued by HRSA/OPA, CMS, and Joint Commission that

affect the hospital’s 340B operations.

Completes Apexus 340B University within six months of hire and

maintains current knowledge as guidance is updated.

Maintains licensure/certification in active status and supplies

documentation required for primary source verification of

credentials (HR 11.01.03).

Self-Development

Key Components: maintain

license/certification, education

and training

2.

3.

2000 Mowry Avenue

Fremont, CA 94538

510.797.1111

www.washingtonhealth.com

Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5

4.

5.

6.

Completes competency assessment at orientation and at least

once every three years, or more frequently as determined by the

organization (HR 11.04.01, EP 1).

Participates in ongoing education and training necessary to

maintain or increase competence, including 340B program and

data analysis training (HR 11.03.01).

Attends and completes all required health and safety classes,

updates, and health screenings/testing (NPG Goal 12).

Seeks out opportunities to learn and apply best practices.

Must be able to demonstrate the knowledge and skills necessary to

provide service based on the physical, psycho/social, educational,

safety, and related criteria appropriate to the age of the patients

served in his/her assigned service area.

7.

8.

1.

2.

Demonstrates awareness of and compliance with regulatory

standards; i.e., 340B federal requirements (HRSA Office of

Pharmacy Affairs), CMS Conditions of Participation — including

Pharmaceutical Services (42 CFR §482.25), Joint Commission

Accreditation 360 standards and National Performance Goals

(NPGs), Title 22, HIPAA, and other service specific regulations.

Performs all work in a manner consistent with 340B program

integrity requirements under section 340B of the Public Health

Service Act (42 U.S.C. §256b), including the prohibitions on

diversion to ineligible individuals and on duplicate discounts and,

as applicable to the hospital’s covered entity type, the group

purchasing organization (GPO) prohibition and orphan drug

exclusion.

Regulatory Compliance

Key Components: Joint

Commission Accreditation 360

standards and National

Performance Goals (NPGs),

CMS Conditions of

Participation, Title 22, OIG,

HIPAA, State/Federal laws,

hospital policies

3.

4.

Supports compliance with Joint Commission Medication

Management requirements as they apply to 340B purchasing,

inventory, and storage records, including management of drugs

and biologicals in accordance with federal and state law (MM

11.01.01), the medication formulary (MM 12.01.01), and medication

storage, records and disposition (MM 13.01.01).

Handles 340B claims, split-billing, and reporting data consistent

with Information Management requirements for privacy,

confidentiality, security, and integrity of health information (IM

12.01.01 and IM 12.01.03), and uses only approved standardized

terminology, abbreviations, acronyms, symbols, and dose

designations (IM 13.01.01).

5.

6.

7.

Employees in this position have access to protected health

information (includes demographics, date of service,

insurance/billing, medical record summary information, and all

other information that may be contained in patient records).

Maintains auditable 340B records and working files sufficient to

demonstrate compliance to HRSA, manufacturers, and the

hospital’s compliance function throughout the applicable audit look-

back period.

Reports suspected noncompliance promptly through the Pharmacy

340B Program Coordinator or the hospital’s compliance reporting

2000 Mowry Avenue

Fremont, CA 94538

510.797.1111

www.washingtonhealth.com

Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5

channels, and does not independently resolve or dispose of

potential program integrity issues.

8.

9.

Knows and complies with all Hospital safety policies and

procedures as identified in the Hospital Safety Manual, Disaster

Preparedness Manual and the Employee Safety Handbook,

including Physical Environment (PE) requirements.

Completes workplace violence prevention training and reports

workplace violence events in accordance with hospital policy (NPG

02.04.01, EP 2), supporting the organization’s workplace and

patient safety goal (NPG Goal 11).

10.

11.

Knows and uses the right safety practices and equipment or

materials.

Takes immediate action and/or reports to supervisor or other

appropriate personnel any potential unsafe condition, practice or

hazard.

12.

Immediately reports every work related injury.

Prepared by:

Approved by:

Minh-Thu Dennen

Title: Director of Pharmacy

Date: 07/2026

7/28/2026

Title: Sr VP & Chief

Operating Officer

Date:

7/29/2026

Personnel Office Review:

Revised Date:

Date:

2000 Mowry Avenue

Fremont, CA 94538

510.797.1111

www.washingtonhealth.com

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