Business Systems Analyst – Pharmacy / Rx Data (Payer Systems)Type: Contract-to-Hire
Location: Hybrid. 2 consecutive days per month onsite, minimum. More frequently would be preferred.
Position OverviewWe are seeking a seasoned Business Systems Analyst (BSA) with deep experience in pharmacy data, Rx lifecycle management, and payer-side pharmacy benefit operations. This role will be responsible for gathering, analyzing, and documenting business and technical requirements supporting data integration, cost management, and formulary analytics across the pharmacy domain of a payer-side client.
The ideal candidate will possess strong knowledge of pharmacy claims adjudication, drug utilization processes, and regulatory compliance (HIPAA, CMS Part D), combined with hands-on data analysis skills using SQL and SAS. The position requires close collaboration with data, architecture, and business teams to translate complex pharmacy workflows into actionable specifications that drive enterprise data and analytics initiatives.
Key Responsibilities - Business Systems Analyst – Pharmacy / Rx Data (Payer Systems)Requirements Gathering & Analysis - Partner with business, data, and technical teams to define requirements related to pharmacy claims, formulary management, and Rx lifecycle processes.
- Analyze business needs and translate them into detailed functional and technical specifications for system enhancements, data integrations, and reporting solutions.
- Document end-to-end workflows for pharmacy claims adjudication, drug coverage determination, and cost management processes.
- Support data mapping, interface design, and validation for payer pharmacy systems.
Pharmacy & Rx Domain Expertise
- Apply strong understanding of the Pharmacy Benefit Management (PBM) ecosystem and payer-side integration requirements.
- Demonstrate expertise in how formularies are structured, maintained, and utilized in pricing and benefit design.
- Understand the Rx claims adjudication lifecycle, including submission, pricing, edits, approvals, and reimbursement.
- Interpret drug utilization data and support initiatives related to cost control, benefit optimization, and clinical outcomes.
- Work with teams to ensure compliance with HIPAA, CMS Part D, and other applicable federal regulations governing pharmacy data exchange and storage.
Data Analysis & Validation - Perform data querying, profiling, and validation using SQL and SAS to ensure data integrity across multiple pharmacy data sources.
- Collaborate with data engineers and analysts to validate source-to-target data transformations.
- Support development of test cases and participate in UAT to ensure accuracy and completeness of implemented solutions.
Cross-Functional Collaboration - Act as a liaison between business stakeholders, data teams, and IT to ensure requirements are properly interpreted and implemented.
- Participate in sprint planning and review sessions to align deliverables with overall data strategy.
- Communicate complex technical findings in clear, business-friendly terms.
Documentation & Reporting - Create and maintain BRDs, FRDs, data mapping documents, and workflow diagrams to support both functional and technical stakeholders.
- Track and report on progress, dependencies, and risks for assigned deliverables.
Qualifications Business Systems Analyst – Pharmacy / Rx Data (Payer Systems) - Bachelor’s degree in Computer Science, Information Systems, Healthcare Informatics, or a related field.
- 7+ years of experience as a Business Systems Analyst in healthcare payer or pharmacy data environments within payer organizations.
- Strong knowledge of Rx lifecycle processes, pharmacy claims adjudication, and formulary management within payer organizations.
- Experience with federal drug databases (e.g., NDC, RxNorm, FDA, CMS).
- Understanding of PBM processes, Part D regulations, and HIPAA compliance.
- Hands-on SQL and SAS experience for data querying, analysis, and validation.
- Proven ability to document functional and technical requirements with precision.
- Excellent analytical, communication, and stakeholder management skills.
- Must have payer-side experience (not focused solely on PBM or retail pharmacy operations).
Preferred Skills Business Systems Analyst – Pharmacy / Rx Data (Payer Systems) - Familiarity with pharmacy rebate or drug pricing data.
- Experience working with data warehouses or data lakes supporting pharmacy data domains.
- Exposure to cloud data platforms (Databricks, AWS, Snowflake, Azure).
- Understanding of clinical integration between pharmacy and medical claims data.
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