RxCLAIM SME(Business / Systems Analysis)

Overview

Remote
Depends on Experience
Accepts corp to corp applications
Contract - Independent
Contract - W2
Contract - 12 Month(s)
No Travel Required

Skills

RxCLAIM
Medicaid Managed Care
JIRA
NCPDP
Medicare
ServiceNow
Pricing
Pharmacy
PBM

Job Details

Role: RxCLAIM SME

Location: Remote

Required:

Minimum of 8+ years' experience in PBM operations, with direct involvement in plan design and configuration.

Deep expertise in RxCLAIM or comparable adjudication systems.

Familiarity with NCPDP standards and formulary management.

Strong understanding of Commercial & Medicare benefit structures involving Formularies/Drug lists, Pharmacy Networks and Pricing (Client/Pharmacy)

Excellent analytical and documentation skills, with ability to translate business needs into workflows, flowcharts, Business Mapping documents and Integrated system design deliverables.

Proven success working with cross-functional teams in PBM.

Desired:

Prior experience in Medicare Advantage, Dual Special Needs Plans (D-SNPs), or Medicaid Managed Care.

Knowledge of utilization management rules, clinical edits, and regulatory submissions.

Experience using Agile project management tools like JIRA or ServiceNow.

Education:

Bachelor's degree in relevant field for PBM Business.

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