Pharmacy Benefit Management (PBM) SME Openings

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Serve as a client-facing PBM Subject Matter Expert specializing in Medicaid pharmacy benefit programs, supporting large-scale PBM implementations, testing, and operational readiness initiatives. Partner directly with business stakeholders, implementation teams, and testing organizations to validate benefit configuration, claims adjudication, Preferred Drug Lists (PDLs), and clinical programs while ensuring compliance with Medicaid regulations and NCPDP standards.

Key Responsibilities

Client Engagement & Advisory: Act as the primary PBM SME for client discussions, requirement validation, solution walkthroughs, workshops, UAT support, and implementation readiness activities.

Medicaid PBM Implementation Support: Support end-to-end PBM implementation initiatives including benefit configuration validation, data conversion testing, business rule verification, and operational readiness.

Claims Adjudication Testing: Validate Medicaid pharmacy claim processing, pricing, reimbursement, eligibility, accumulators, and benefit application using NCPDP transaction standards.

PDL & Clinical Program Validation: Validate Preferred Drug Lists (PDLs), Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), DUR edits, and preferred/non-preferred drug logic.

NCPDP Standards Expertise: Validate NCPDP D.0 transaction processing, reject codes, pharmacy messaging, COB processing, and adjudication responses.

Pricing & Reimbursement Validation: Verify MAC pricing, ingredient cost calculations, dispensing fees, reimbursement methodologies, and pharmacy payment accuracy.

Defect Analysis & Business Support: Lead defect triage, root cause analysis, business rule interpretation, and resolution discussions with client

Requirements & Solution Validation: Review business requirements, state program rules, and implementation artifacts to ensure alignment with Medicaid PBM operations.

Best Regards,
Yogesh Bisht
Assistant Manager

VBeyond Corporation |

Note VBeyond is fully committed to Diversity and Equal Employment Opportunity.