RxCLAIM SME

Job Title: RxCLAIM SME

Location: Remote

Duration: Long term

Tax Term: W2

Key Technology: RxClaim, PBM

Job Responsibilities:

• Act as a subject matter expert in pharmacy benefit plan design across RxCLAIM or similar adjudication platforms.
• Create Current state flows for each functional component and their interactions with benefit build process within RxCLAIM and downstream applications.
• Develop and document plan designs including tier structure, copays, accumulators, exclusions, step therapy, quantity limits, and PA requirements.
• Collaborate with actuarial, clinical, and compliance teams to ensure benefit integrity.
• Conduct configuration reviews, impact assessments for new plans or changes.
• Serve as the liaison between IT configuration, operations, and product teams to drive plan design best practices.
• Analyze and resolve issues in plan setup, discrepancies in benefit outcomes, or member escalations.
• Ensure compliance with CMS, state, and PBM-specific requirements.

Skills and Experience Required:

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.