Pharmacy Benefit Management (Business Integration Specialist)

Location: Raleigh, North Carolina, USA

Duration: 8 Months (Hybrid)

Visa Status: USC,GC, GCEAD, H1b, C2C

Job Description:

The PBM Business Integration Specialist will serve as a member of the Client Medicaid Enterprise System (MES) Program within Pharmacy Business space. The PBM Business Integration Specialist will provide expertise and business support to the Pharmacy and Ancillary Services Business Unit in the development and implementation of the Medicaid Enterprise Modular Pharmacy Business Management (PBM) Solution. The PBM Business Integration Specialist, as a Business Subject Matter Expert, will assist the Department to on-board the PBM vendor, serve as a business stakeholder, and represent the Pharmacy Business Unit in the implementation of the complex and innovative PBM Solution.
The primary responsibility of this position is to serve as the subject matter expert and content lead in collaboration with the Pharmacy Business team for Clinical policies and Prior Authorizations, Drug Utilization Review (DUR) and pharmacy lock-in related processes, Behavioral health, and A+ kids, Preferred Drug List (PDL) and Medicaid Drug Rebate Program (MDRP), and Physicians Administered Drug Program (PADP) related to the Medicaid Drug Rebate Program (MDRP).
The Pharmacy team needs a Business Integration Specialist who is dedicated to the PBM Module Implementation and can focus on these work streams as they relate to implementation of the new PBM, in collaboration with the existing pharmacy team.
Knowledge of Medicaid Pharmacy Benefits Management processes, intended outcomes, and pain points is essential.
This position will actively work with the Pharmacy Business team to define and provide the business support in completing the business process documents, Business use cases, Business case scenarios, user acceptance test case scenarios, and documentation in relation to Medicaid initiatives and strategic goals. This position may require interacting with the NC Medicaid Business Information Analytics Office, DHHS Data Office, Information Technology Division, Privacy and Security Office, Policy Office, General Counsel, Office of Procurement, Contracts and Grants, among others.
Roles and Responsibilities
• Supports one or more Pharmacy business process areas, including.
o Clinical policies and Prior Authorizations.
o Drug Utilization Review (DUR) and pharmacy lock-in related processes
o Behavioral health, and A+ kids.
o Preferred Drug List (PDL) and Medicaid Drug Rebate Program (MDRP)
o Physicians Administered Drug Program (PADP) related to the Medicaid Drug Rebate Program (MDRP)
• Supports cross-functional activities that provide effective oversight of Medicaid Programs.
• Collaborates and communicates with the PBM Business stakeholders (Product Managers, Product Owners, Business Leads.)
• In-depth knowledge and understanding of the business needs across functions and business segments in healthcare that meet departmental goals.
• Ability to research and recommend the development and implementation of business initiatives of the product enhancements.
• Provides feedback and input to senior level decision-makers to develop long-range strategic alternatives for business solutions.
• Preferred to have experience with Medicaid, managed care, and Pharmacy Benefit Manager (PBM) operations. areas.
• Prior experience with Medicaid applications and preferably across Pharmacy Functional Areas.
• Communicate with the business owner needs and help translate them into detailed and actionable requirements as needed.
• Ensures compliance with all applicable policies and procedures.
• Supporting the product lifecycle from conception through implementation.
• Performs other duties as assigned.
In addition, the Pharmacy Business Integration Specialist is responsible in supporting the Business Management space to achieve successful development of the Pharmacy Benefit Management Solution in support of the Medicaid program. The Business Integration Specialist will work collaboratively with the Business owner and the rest of the business team to develop the strategy behind how each MES module will support the business requirements definition as well translation and specification of all functional requirements.
Education and Experience (Required):
• Graduation from an accredited School of Pharmacy
• B.S. or Doctor of Pharmacy degree required.
• Registered Pharmacist with a valid and unrestricted Pharmacist license
• 3+ years of professional experience, preferably within a Medicaid agency or Pharmacy Benefit Manager (PBM)
• Understanding of pharmacy lines of business: retail, long term care, home infusion, mail order, specialty, institutional
• Drug information skills
• Analytical skills
• Computer proficiency with Microsoft Office (Word, Excel, PowerPoint) products
• Skills to handle multiple priorities and manage communications professionally to achieve issue resolution with customers, employees, or management.
License or Certification required by statue or regulation: (Is a license or certificate required? What kind and type?)
• Licensed to practice pharmacy in the State of North Carolina or the ability to receive the North Carolina license to practice Pharmacy within 90 days of hire.
Required 4 Years. Graduation from an accredited School of Pharmacy, B.S. or Doctor of Pharmacy degree
Required 3 Years. Registered Pharmacist with a valid and unrestricted Pharmacist license
Required 3 Years. Licensed to practice pharmacy in the State of North Carolina or the ability to receive the North Carolina license to practice Pharmacy within 90 days
Required 3 Years. Understanding of pharmacy lines of business: retail, long term care, home infusion, mail order, specialty, institutional
Required 3 Years. Skills to handle multiple priorities and manage communications professionally to achieve issue resolution with customers, employees, or management
Required 3 Years. Knowledge of the Medicaid Pharmacy (PBM) processes, roles, and intended outcomes
Required 3 Years. Drug information skills
Required 3 Years. Experience in ensuring with all applicable policies and procedures.
Desired 1 Years. Knowledge of the Enterprise IT Systems integration principle and associated change management best practices
Required 3 Years. Demonstrate ability to manage multiple priorities and projects, and function in a fast passed moving constantly changing, deadline-driven environment
Required 3 Years. Proficient in Microsoft Word, Excel, PowerPoint, Access, and Adobe software
Required 3 Years. Experience in reviewing and providing feedback and input to senior level decision-makers to develop long-range strategic alternatives for business sol
Required 3 Years. Experience working in a combination of business analysis. Product management, project management, and or software application development
Required 3 Years. Excellent communication skills and attention to detail with specific experience developing, editing, and presenting summaries, reports, and complex in
Highly desired 2 Years. Proven experience and working knowledge of the agile development methodologies, environment and tools.
Required 3 Years. Experience handling HIPPA and PII data.
Required 3 Years. Managed care knowledge or experience
Required 3 Years. Medicaid program knowledge or related Healthcare Information experience


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