Pharmacy Benefits Management (PBM)

Minimum Qualifications: EXPERIENCE LEVEL: • 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. PBM SUBJECT MATTER EXPERTISE: • 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 First Data 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 inhouse training) Non-Domain Expertise: • 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 • Experience with SQL queries and understanding Data Models is a strong plus. Job Responsibilities: • Provide PBM Subject Matter Expertise for both Conduent (Development and Testing team) and non-Conduent 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 using Microsoft Excel is needed to be effective at Requirements management, Translating and simplifying requirements. • Document product features/requirements related documentation, prepare roadmaps (with aid of tools such as Visio, Power point)