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
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

Benefits

generous, flexible vacation policy
educational assistance
comprehensive health benefits
401(k) employer match
leadership and technical development academies

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

Business Requirements Documents (BRDs)Functional Requirements Documents (FRDs)user storiesprocess flowsdata mappingsSQLNCPDP standardsEDI transactionsAgileScrum

Soft Skills

analytical skillsproblem-solving skillscommunication skillsstakeholder managementprocess improvement