Gainwell TechnologiesRemote
Senior Business Analyst - Pharmacy Benefit Management (PBM)
United States
Full-time
5 days ago
$69,000 - $99,000 USD
H1B Sponsor Likely
Key skills
Pharmacy Benefit ManagementRequirements gatheringPharmacy claims adjudicationSQLNCPDP standardsAgile methodologiesAnalytical skillsProblem-solving skillsCommunication skillsAttention to detailDocumentation skillsAgileScrumStakeholder ManagementCommunication
About this role
Gainwell Technologies is a company focused on improving health and well-being through innovative technology solutions. They are seeking a Senior Business Analyst with expertise in Pharmacy Benefit Management to lead requirements gathering, collaborate with stakeholders, and ensure high-quality solutions for PBM operations.
Responsibilities:
- Lead requirements gathering sessions with business stakeholders, SMEs, and cross-functional teams
- Translate business needs into detailed Business Requirements Documents (BRDs), Functional Requirements Documents (FRDs), user stories, process flows, and data mappings
- Analyze and document current and future-state workflows within PBM operations
- Demonstrate strong knowledge of the pharmacy claims adjudication lifecycle, including:
- Member eligibility validation
- Formulary checks
- Benefit plan design
- Prior authorization
- DUR (Drug Utilization Review)
- Copay/coinsurance calculation
- Rejections and overrides
- Work closely with IT teams to support system enhancements, integrations, and defect resolution
- Participate in system design discussions and provide functional guidance to developers
- Support EDI transactions including NCPDP standards
- Create test plans, test cases, and support SIT/UAT activities
- Perform data analysis using SQL or similar tools to validate requirements and results
- Ensure compliance with regulatory requirements (CMS, HIPAA)
- Identify process improvement opportunities and recommend solutions
Requirements:
- 5+ years of experience in Pharmacy Benefit Management (PBM)
- Strong client facing experience with expertise in requirements gathering, documentation
- Deep understanding of the pharmacy claims adjudication process
- Lead requirements gathering sessions with business stakeholders, SMEs, and cross-functional teams
- Translate business needs into detailed Business Requirements Documents (BRDs), Functional Requirements Documents (FRDs), user stories, process flows, and data mappings
- Analyze and document current and future-state workflows within PBM operations
- Demonstrate strong knowledge of the pharmacy claims adjudication lifecycle, including member eligibility validation, formulary checks, benefit plan design, prior authorization, DUR (Drug Utilization Review), copay/coinsurance calculation, rejections and overrides
- Work closely with IT teams to support system enhancements, integrations, and defect resolution
- Participate in system design discussions and provide functional guidance to developers
- Support EDI transactions including NCPDP standards
- Create test plans, test cases, and support SIT/UAT activities
- Perform data analysis using SQL or similar tools to validate requirements and results
- Ensure compliance with regulatory requirements (CMS, HIPAA)
- Identify process improvement opportunities and recommend solutions
- Strong understanding of PBM operations and pharmacy claims adjudication
- Proven experience gathering and documenting detailed business and functional requirements
- Strong analytical and problem-solving skills
- Experience working in Agile, Scrum, or Waterfall environments
- Excellent communication and stakeholder management skills
- Basic to intermediate SQL for data validation and analysis
- Familiarity with APIs, system integrations, and data mapping
- Understanding of system architecture and data flow diagrams