Project Manager II

Mason, Ohio
UST

Role Proficiency:

Responsibilities

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

• Drive / Review Claim processing needs
• 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 6 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 7 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