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Business Analyst - Pharmacy

Financial Planning and AnalysisFinancial Planning and AnalysisOtherRemoteTeam 10,001+H1B SponsorCompany SiteLinkedIn

Location

United States

Posted

117 days ago

Salary

0

No structured requirement data.

Job Description

Business Analyst - Pharmacy

Gainwell Technologies

As a Business Analyst - Pharmacy at Gainwell, you will deliver high-impact Medicaid and public health technology solutions to improve health outcomes and operational efficiency. Support pharmacy benefit management (PBM) programs, Medicaid pharmacy operations, and pharmacy IT solution delivery. Bridge business needs and technical solutions by analyzing requirements, enhancing pharmacy systems, supporting compliance, and ensuring accurate delivery of pharmacy services and claims processing capabilities. Your role in our mission includes: Business Analysis & Requirements: Gather, document, and validate business, functional, and technical requirements for pharmacy IT systems (e.g., POS, DUR, pharmacy claims processing, RTBT, Preferred Drug Lists). Translate regulatory and policy updates (CMS, Medicaid pharmacy rules, rebate programs) into system impacts and requirements. Work closely with business stakeholders, pharmacists, SMEs, and IT teams to define scope and acceptance criteria. Gather, document, and validate business, functional, and technical requirements for pharmacy IT systems (e.g., POS, DUR, pharmacy claims processing, RTBT, Preferred Drug Lists). Translate regulatory and policy updates (CMS, Medicaid pharmacy rules, rebate programs) into system impacts and requirements. Work closely with business stakeholders, pharmacists, SMEs, and IT teams to define scope and acceptance criteria. Pharmacy IT & System Support: Analyze pharmacy claims processing logic, NCPDP standards, pricing and reimbursement methodologies, and drug file updates. Assist in system design relating to DUR, PA workflow, clinical edits, drug coverage modules, formulary management, and rebate processing. Create and update use cases, data mappings, workflows, and system configuration documentation. Analyze pharmacy claims processing logic, NCPDP standards, pricing and reimbursement methodologies, and drug file updates. Assist in system design relating to DUR, PA workflow, clinical edits, drug coverage modules, formulary management, and rebate processing. Create and update use cases, data mappings, workflows, and system configuration documentation. Testing & Quality Assurance: Develop test plans, scenarios, and scripts for pharmacy-related system enhancements. Perform UAT, regression testing, and validation of changes to pharmacy modules. Document defects, work with technical teams to resolve issues, and confirm results meet requirements. Develop test plans, scenarios, and scripts for pharmacy-related system enhancements. Perform UAT, regression testing, and validation of changes to pharmacy modules. Document defects, work with technical teams to resolve issues, and confirm results meet requirements. Project & Stakeholder Management: Support project planning, sprint activities, and cross-functional coordination for release cycles. Provide regular updates, prepare business/technical documentation, and contribute to status reports. Facilitate meetings, requirement workshops, and stakeholder reviews. Support project planning, sprint activities, and cross-functional coordination for release cycles. Provide regular updates, prepare business/technical documentation, and contribute to status reports. Facilitate meetings, requirement workshops, and stakeholder reviews. Operational & Compliance Support: Monitor and interpret pharmacy program policies, CMS guidelines, and regulatory changes for system impact. Support operational teams in analyzing claim issues, pricing discrepancies, and pharmacy provider concerns. Assist in audit support, documentation, and compliance-driven deliverables. Monitor and interpret pharmacy program policies, CMS guidelines, and regulatory changes for system impact. Support operational teams in analyzing claim issues, pricing discrepancies, and pharmacy provider concerns. Assist in audit support, documentation, and compliance-driven deliverables.

Job Requirements

  • 3+ years of experience in business analysis within healthcare or pharmacy IT environments.
  • Bachelor’s degree in Business, Healthcare, Information Systems, Pharmacy, or related field.
  • Strong understanding of pharmacy benefit management operations and terminology.
  • Familiarity with NCPDP standards, pharmacy claims processing, drug file management (Medi-Span/First Databank), and pricing methodologies (strongly preferred).
  • Experience writing business requirements, user stories, and test scenarios.
  • Proficiency with MS Office, JIRA/Azure DevOps (ADO), Visio, or similar tools.
  • Excellent analytical, documentation, communication, and problem-solving skills.
  • Experience with Medicaid pharmacy programs, MMIS, or PBM systems.
  • Understanding of Clinical and DUR rules, formulary management, rebates, and PA workflows.
  • Certification(s): CBAP, PMI-PBA, Agile/Scrum, or Pharmacy Technician (CPhT).
  • Knowledge of CMS Medicaid regulations (e.g., CMS 42 CFR Part 455, OUD policies, CMS drug rebate programs).

Benefits

  • Generous, flexible vacation policy.
  • 401(k) employer match.
  • Comprehensive health benefits.
  • Educational assistance.
  • Leadership and technical development academies to help build your skills and capabilities.

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