Position: 100% Remote Senior Business Analyst with Strong PBM / Health Plan
Employment Type: Contract
Work Arrangement: Remote
Industry: Healthcare / Pharmacy Benefit Management
Position Overview
We are seeking an experienced Senior Business Analyst to support a growing portfolio of healthcare and pharmacy benefit management initiatives. This individual will serve as a key liaison betweenbusiness operations, technical teams, and other stakeholders, helping translate complex operational needs into clear functional and technical requirements.
The ideal candidate will have strong hands-on experience within PBM and health plan environments, with a solid understanding of pharmacy claims, eligibility, benefits, accumulators, and the systems and data that support these functions.
This role requires someone who can quickly understand complex healthcare operations, identify downstream impacts, analyze data and requirements, and work across both business and technology teams to support successful solution delivery.
Key Responsibilities
- Partner with PBM, health plan, operational, business, and technology stakeholders to understand business needs and translate them into functional and technical requirements.
- Lead requirements-gathering sessions, stakeholder interviews, workshops, and process reviews.
- Document business requirements, functional requirements, workflows, business rules, use cases, and acceptance criteria.
- Perform impact analysis to identify how proposed changes may affect pharmacy claims, eligibility, benefits, accumulators, downstream systems, and operational processes.
- Analyze pharmacy claims processing workflows and associated business rules.
- Support requirements and analysis related to member eligibility, benefit configuration, and accumulator processing.
- Perform data analysis, data validation, and file/interface mapping across healthcare and PBM systems.
- Partner with technical teams to ensure business requirements are accurately translated into system functionality.
- Develop and support testing strategies, test scenarios, test cases, and validation activities.
- Participate in SIT, UAT, defect analysis, and issue resolution as appropriate.
- Analyze production or implementation issues and work with business and technical teams to determine root causes and solutions.
- Identify upstream and downstream dependencies and communicate potential operational impacts to stakeholders.
- Support regulatory, compliance, and business-driven initiatives affecting PBM and health plan operations.
- Maintain clear documentation and provide regular updates regarding requirements, risks, issues, dependencies, and deliverables.
Required Qualifications
- Strong Business Analyst experience within healthcare payer, health plan, and/or Pharmacy Benefit Management (PBM)environments.
- Strong understanding of PBM and health plan operations.
- Experience with pharmacy claims processing.
- Experience with eligibility, benefits, and accumulators.
- Strong requirements gathering, documentation, and impact-analysis experience.
- Experience developing or supporting testing strategies, test cases, and validation.
- Strong data-analysis skills, including experience with file mapping and data validation.
- Demonstrated ability to work effectively with both business and technical stakeholders.
- Ability to understand complex operational processes and translate business needs into clear functional and technical requirements.
- Strong analytical, problem-solving, communication, and documentation skills.
- Ability to work across multiple teams and quickly become productive in a complex healthcare environment.
Preferred Qualifications
- Experience with NCPDP standards and pharmacy transaction formats.
- Experience supporting regulatory or compliance-driven healthcare initiatives.
- Previous experience supporting F6-related initiatives or programs.
- Experience with large-scale PBM implementations, migrations, or transformation initiatives.
- Familiarity with healthcare data exchanges, interfaces, and downstream dependencies.
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