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
- At least 2 years working experience in Business engagements in healthcare
- industry, preferably in Pharmacy Benefit Manager (PBM) / Pharmacy spectrum
- Pharmacy Benefit Manager (PBM) / Pharmacy spectrum as Business Analyst – with core Business team
- More than 3 years total healthcare experience
- Demonstrated Working experience in Payer-PBM interfaces (few key entities from Pharmacy/PBM spectrum)
- Subrogation Claim Processing
- Member Eligibility
- Product/Benefit
- Claim Processing
- Prior Authorization
- Formulary
- Consumer/Member portals & Mobility applications
- Medicare/Medicaid, PDE, Encounter
- Coordination of Benefits
- NCPDP layout and EDI Rx transactions
- Specialty Pharmacy
- Mail order Pharmacy
- Excellent knowledge in Elicitation of Business requirements by collaborating with
- Business sponsors
- Efficient in translating Business Requirements into Functional and Non-Functional
- Requirements
- Strong communication skillset who can be engaged with business stakeholders as
- Pharmacy domain SME
- Experienced in User Acceptance Testing (UAT)
- Strong exposure to Agile and Waterfall - Model and tools (eg: JIRA, Confluence etc)
Good to have
- Working experience with PBM migration with any of the leading Payers
- Certified in Agile practices - SAFe® Practitioner, Scrum Master etc
- Certifications in Business Analysis