PBM Principle Solution Architect
Location: Remote – may have to go on site once a quarter (Baltimore MD) (especially once a permanent employee)
Exp: 18-20+yrs
This is for a PBM Solution Architect with 10 years of PBM minimum
Healthcare Payor experience required
Required : 834 / 837 edi transactions
Facets and Edifacs integrations nice to have
Proficiency in innovating ideas and solutions resulting in tangible and measurable business outcomes.
Mastery in creating architecture solutions within the enterprise architecture future state for technological acceleration of value outcomes, and effectively present and persuade key decision makers to invest in this acceleration.
Healthcare Payer and PBM Operations: Deep knowledge of and experience with health insurance and Pharmacy Benefit Management (PBM) business models, processes, capabilities, and supporting information systems, including pharmacy benefit design, formulary management, drug pricing, pharmacy networks, eligibility, claims, rebates, utilization management, specialty pharmacy, and member/provider services.
Pharmacy Benefit Administration: Strong understanding of the end-to-end pharmacy benefit lifecycle, including benefit configuration, formulary and drug list management, prior authorization, step therapy, quantity limits, accumulator management, specialty drugs, pharmacy network administration, claims adjudication, reversals, coordination of benefits, and payment/reconciliation.
Healthcare Payer Architecture: Comprehensive knowledge of, and experience with, payer business capabilities and the relationships among Membership/Enrollment, Benefits, Provider Management, Claims, Care Management, Utilization Management, Pharmacy, Billing, Finance, Customer Service, and Digital/Mobile capabilities.
PBM Ecosystem: Understanding of the integration points among health plans, PBMs, pharmacies, pharmacy networks, pharmaceutical manufacturers, wholesalers, clearinghouses, providers, members, and government/regulatory organizations.
Healthcare Interoperability Standards and Regulations: Working knowledge of HIPAA, CMS requirements, NCPDP standards, HIPAA EDI transactions (e.g., HL7, FHIR, X12), Medicare Part D, Medicaid pharmacy requirements, and applicable federal and state pharmacy regulations.
Healthcare Integration: Strong understanding of API, event-driven, batch, EDI, and real-time integration patterns used to exchange eligibility, benefit, provider, pharmacy, drug, claims, authorization, and financial information.
Ability to define canonical data models, information flows, integration contracts, APIs, events, and data governance requirements.
Ability to evaluate commercial products and platforms and make buy/build/reuse/replace recommendations.
Ability to motivate and influence others so that architecture objectives are met in a timely and consistent manner
Ability to collaborate with stakeholders to develop high quality, architecture solutions and technical designs based on approved standards.
Ability to coach peers and team members across multiple business and technology disciplines.
Ability to provide solution architectural consulting to business leaders, program leaders, product owners, and delivery teams
Ability to set architectural solutions across multiple initiatives or domains aligned to platform/product roadmaps and facilitate implementation of approved solution.
Effective organizational/interpersonal/relationship management, analytical/systems thinking, communications (written and verbal) and collaboration across multiple business and IT teams.
PURPOSE:
Responsible for establishing strategic technology direction and creating solution architecture for large complex initiatives/projects. Responsible for the strategic design of technical solutions for complex business problems that are in line with established and emerging technology standards, patterns, and best practices. Primary accountability for architecture work takes place during the lifecycle of major transformation/modernization Initiatives/projects, from planning through implementation. Provides technical oversight and strategic direction to IT project teams in order to deliver key solutions to business problems.
ESSENTIAL FUNCTIONS:
40% Translate business strategy into solution architecture:
Accountable for leading the Solution Architecture deliverables for large complex portfolio, program or product line, which aligns with enterprise architecture and links the high-level architecture, business requirements, and technology standards into a cohesive solution. Responsible for defining and communicating a shared technical and architecture vision across the portfolio/program. Provides foundational architecture and creates technical alignments for the full solution balancing the needs from both business and domain architecture. Has an expert knowledge of integration solutions and communicates with business owners, domain architects, other Solution Architects, technical delivery staff, and key technical stakeholders, including Security, Data, and Technology Centers of Excellence. Collaborates with peer Solution Architects to ensure that the proposed solution is consistent with other designs.
20% Leads Solutions Design and Analysis:
Leads solutions design incremental and analysis of complex projects/issues that require in-depth knowledge across multiple technical areas and business segments. Responsible for defining components and subsystem, end to end integration architecture and their interface, as well as the target deployment aligning with target architecture vision. Responsible for recommendations of critical design decisions and trade-offs. Ensures seamless integration of new applications with enterprise applications in the ecosystem by selecting the technology, tools or services that provides the best solution for business needs.
20% Orchestrate solution delivery:
Accountable for communicating solution architecture and getting it implemented. Defines and directs implementation governance activities associated ensuing solution architecture compliance with the intent and overall enterprise architecture. Responsible for creates architecture and technical enablers to support architecture runways. Supports the implementation of enablers and ensures solution of technical and architecture enablers meet solution objectives.
10% Facilitate and collaborate to drive business value:
Partners with the project manager, product managers technical delivery manager, requirements manager, and business leadership in the definition of the Solution Architecture.Work closely with product managers, product owners to ensure a robust architecture runways that can support future business needs through product lifecycle. Provide consulting supports to domain architects and solution delivery team to ensure project and product aligned with overall enterprise architecture.
10% Maintain industry and technology Expertise:
Maintains knowledge of and apply industry best practices for architecture, participates in cross-functional component architecture teams, and develops future architecture and technology migration plans. Evaluates and selects from existing and emerging technologies options best fitting business and IT strategic needs.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Bachelor''s Degree
Education Details: Computer Science, IT related field
Experience: 10 years experience as an infrastructure architect
In Lieu of Education
In lieu of a Bachelor''s degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Preferred Qualifications
Master’s degree in Computer Science or related field preferred. Experience in the development, implementation, and maintenance of large-scale systems, preferably across multiple hardware and software platforms (in the health care industry). Experience with intranet development and implementation is a plus.
Knowledge, Skills and Abilities (KSAs)
Strong development and integration technology experience, Expert
Excellent communication skills both written and verbal., Expert
Ability to lead, coordinate, and manage complex projects., Expert
Solution architecture and integration architecture design experience, Expert
Deep understanding of emerging technologies, including cloud, big data, BPM, AI/ML, or robotics etc, Expert
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