Senior Business Analyst - Pharmacy Benefit Management (PBM)

Gainwell Technologies is a company that aims to improve the health and well-being of vulnerable communities through innovative technology solutions. The Senior Business Analyst will lead requirements gathering and collaborate with stakeholders to enhance Pharmacy Benefit Management operations, ensuring high-quality solutions that address healthcare challenges.

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 as a Business Analyst in a PBM environment
• Strong understanding of PBM operations and pharmacy claims adjudication
• Experience with Medicaid plans
• Proven experience gathering and documenting detailed business and functional requirements
• Familiarity with NCPDP standards and EDI transactions
• Strong analytical and problem-solving skills
• Experience working in Agile, Scrum, or Waterfall environments
• Excellent communication and stakeholder management skills
• 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 attention to detail
• Ability to manage multiple priorities
• Excellent documentation and presentation skills
• Ability to bridge communication between business and technical teams
• Proactive and solution-oriented mindset
• 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