Pharmacy Management PBM SME and Business Analyst

JOB TITLE: PHARMACY BENEFITS MANAGEMENT PBM SME and BUSINESS ANALYST

JOB LOCATION: Remote

WAGE RANGE*: $50HR TO $55HR W2
JOB NUMBER: 26-00111

REQUIRED EXPERIENCE:

Provide PBM Subject Matter Expertise for both Development and Testing team and stakeholders (e.g. Customers). Candidate should have deep understanding of Pharmacy Benefit Management (PBM) business processes – including Claims Adjudication, Data related processes (e.g. Eligibility data, Provider data, Drug data, Formulary data, Drug Utilization reviews) and their interconnections. Strong plus if candidate has experience with Electronic Prescriptions and Prior-Authorizations related standards.

Deep understanding of related PBM standards from NCPDP. Strong plus if candidate also understands CMS regulations related to state Medicaid Pharmacy programs.

We are looking to onboard a Senior Business Analyst in Manager role or Individual contributor depending on experience level. This person will have deep PBM domain expertise and who will help guide the roadmap and feature enhancements for the client PBM product suite. This person will serve as a bridge between the Business users and/or Clinical end users (Pharmacists) and the Technical team (Developers and Testers primarily).

• Ideally 10+ years experience working in PBM domain (Claims processing related).
• Willing to consider less experienced candidates who can demonstrate depth in understanding PBM area.

• Candidate should have deep understanding of Pharmacy Benefit Management (PBM) business processes – including Claims Adjudication, Data related processes (e.g. Eligibility data, Provider data, Drug data, Formulary data, Drug Utilization reviews) and their interconnections. Strong plus if candidate has experience with Electronic Prescriptions and Prior-Authorizations related standards.
• Deep understanding of related PBM standards from NCPDP. Strong plus if candidate also understands CMS regulations related to state Medicaid Pharmacy programs.
• Candidate should have deep understanding of Financial Bank (FDB) Drug nomenclature and how to use FDB nomenclature in designing/ configuring drug coverage (inclusions/exclusions/PA Criteria) or building Formulary / Preferred Drug Lists. In lieu of FDB, MEDISPAN data experience will be acceptable.
• Candidate should be well informed about current industry trends and evolving standards.
• College degree is preferred. Industry experience can be considered as substitute.
• Candidates who have strong Clinical background (e.g. Pharmacists) and some BA background are welcome to apply (provided they are willing to switch to being a full‑fledged BA with in‑house training).

• Must understand Software Development Life Cycle – including requirements management.
• Must be able to capture requirements, document requirements and manage requirements using requirements management tools.
• Must be able to document business processes using a combination of tools – Visio, Powerpoint, Excel and Word formats depending on the context and synthesize requirements into user stories, decision tables or other pertinent formats.
• Must have excellent communication and writing skills.
• Experience with SQL queries and understanding Data Models is a strong plus.
• Must be a team player willing to share knowledge and support team members from other areas e.g. Developers and QA Testers.

• Provide PBM Subject Matter Expertise for both Development and Testing team and stakeholders (e.g. Customers).
• Own responsibility for creating requirements specifications / design documents (e.g. wire‑frames, decision tables) to help developers produce technical specifications.
• Own responsibility for configuring drug plan benefits (e.g. Covered drugs, Pricing configuration, PA requirements) using Conduent PBM system.
• Interact with business and clinical users to elicit and understand business requirements, translate the requirements into appropriate format for consumption by Development and Testing team.
• Good working knowledge on creating Process workflow or Use Cases, Powerpoint slides, Wireframes, Workflows using Microsoft Visio, analyze data…