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Gainwell Technologies is an award-winning digital health technology company that supports the administration of healthcare and human services programs. In past
Senior Business Analyst – Pharmacy Benefit Management
Location
Texas
Posted
120 days ago
Salary
$69.4K - $99.2K / year
Seniority
Senior
Job Description
Senior Business Analyst – Pharmacy Benefit Management
Gainwell Technologies
• 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.
Job 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
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