PBM Medicaid Subject Matter Expert (SME)_ Remote

Hiring: PBM Medicaid Subject Matter Expert (SME)

Location: Remote

We are seeking an experienced PBM Medicaid Subject Matter Expert (SME) with strong expertise in Medicaid Pharmacy Benefit Management (PBM), claims adjudication, and PBM implementation projects. This is a client-facing role supporting large-scale Medicaid PBM implementations, testing, and operational readiness initiatives.

Key Responsibilities:

• Serve as the primary PBM SME for client discussions, workshops, solution validation, and implementation readiness.
• Support end-to-end Medicaid PBM implementation, configuration validation, data conversion testing, and business rule verification.
• Validate Medicaid pharmacy claims adjudication, pricing, reimbursement, eligibility, accumulators, and benefit processing.
• Review and validate Preferred Drug Lists (PDLs), Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), and DUR edits.
• Validate NCPDP D.0 transaction processing, reject codes, COB processing, and pharmacy messaging.
• Perform pricing and reimbursement validation, including MAC pricing, ingredient cost calculations, dispensing fees, and pharmacy payments.
• Lead defect analysis, root cause investigation, and business rule validation.
• Collaborate with business stakeholders, implementation teams, and testing organizations to ensure successful project delivery.

Required Skills:

• Deep expertise in Medicaid PBM operations, implementation, and testing.
• Strong knowledge of:
• Medicaid Pharmacy Claims Adjudication
• Preferred Drug Lists (PDLs)
• NCPDP D.0 Standards
• Clinical Programs (PA, ST, QL, DUR)
• Pharmacy Pricing and Reimbursement Methodologies
• Experience supporting PBM implementations, migrations, or modernization initiatives.
• Hands-on experience with PBM platforms such as RxClaim or equivalent.
• Strong understanding of Medicaid FFS and Managed Medicaid programs.
• Excellent client-facing communication and stakeholder management skills.

Preferred Skills:

• Experience with State Medicaid PBM implementations.
• Knowledge of Medicare Part D or Commercial PBM.
• Claims data validation and conversion testing experience.
• Rebate administration and formulary management knowledge.
• Experience leading UAT, business validation workshops, and operational readiness activities.