Business Analyst - Pharmacy Benefit Management (PBM)

Role: Pharmacy Benefit Management (PBM) Business Analyst

Location: Virginia Beach, VA (Remote to start)

Job Details

BSA (PBM)

Pharmacy Benefit Management (PBM) : Business Analyst

Client is looking for a Pharmacy Benefit Management (PBM) Business Analyst to work with one of the leading healthcare providers in US as part of UST's PBM Practice. The ideal candidate must possess excellent background on Pharmacy Benefit Management (PBM) business and Rx domain spectrum.

Responsibilities

As a Pharmacy Benefit Management (PBM) Business Analyst, you will

Process the PBM claims based on business rules

Engage appropriate PBM business stakeholders in reviewing business scenarios and revise the business rules as required

Collaborate with other business functional groups including (but not limited to) Membership and Enrolments, Benefit Configuration, Pricing and Networks, Formulary management, Drug Discounts, Finance and Reporting, Downstream processing areas

Run query from data warehouse applications and claims processing application (s) to triage the reported claims and related issues

Facilitate and/or actively participate in meetings related to the designated project/s, both locally and internationally, with clients and/or partners

Accurately track and report claim status

Support claims review and audit activities

Requirements

(1) At least 2 years working experience in Business engagements in healthcare industry, preferably in Pharmacy Benefit Manager (PBM) / Pharmacy spectrum

(2) Pharmacy Benefit Manager (PBM) / Pharmacy spectrum as Business Analyst with core Business team

(3) More than 3 years total healthcare experience

(4) Demonstrated Working experience in Payer-PBM interfaces (few key entities from Pharmacy/PBM spectrum)

a. Subrogation Claim Processing

b. Member Eligibility

c. Product/Benefit

d. Claim Processing

e. Prior Authorization

f. Formulary

g. Consumer/Member portals & Mobility applications

h. Medicare/Medicaid, PDE, Encounter

i. Coordination of Benefits

j. NCPDP layout and EDI Rx transactions

k. Specialty Pharmacy

l. Mail order Pharmacy

(5) Excellent knowledge in Elicitation of Business requirements by collaborating with Business sponsors

(6) Efficient in translating Business Requirements into Functional and Non-Functional Requirements

(7) Strong communication skillset who can be engaged with business stakeholders as Pharmacy domain SME

(8) Experienced in User Acceptance Testing ( UAT )

(9) Strong exposure to Agile and Waterfall - Model and tools (eg: JIRA, Confluence etc)

Good to have

(10)Working experience with PBM migration with any of the leading Payers

(11)Certified in Agile practices - SAFe Practitioner, Scrum Master etc

(12)Certifications in Business Analysis