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TX PBM Drug File Coordinator

Date:  Nov 17, 2023

Any city, TX, US, 99999

Req ID:  20901


As a TX PBM Drug File Coordinator at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve — a community’s most vulnerable.

Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare’s biggest challenges. Here are the details on this position

Your role in our mission

•    PBM Practice Business Analyst supporting TX Fee For Service Pharmacy module.

•    Support PBM implementations and configurations.

•    Configuration of new NDCs weekly received from First Data Bank (FDB) within our pharmacy system.

•    Configuration of benefits/contracts, payment rules and more.

•    Configure new and revised claims adjudication logic within a pharmacy claims system.

•    Configuration validation, configuration peer review.

•    Perform ad hoc requests via SQL databases on a need basis.

•    Maintain and configure Rx DUR settings.

•    Configuring and loading rule sheets into various PA systems.

•    Troubleshooting and fixing system configuration errors, performing investigations and root cause analysis of submitted tickets, and ensuring day to day issues are identified and appropriately addressed.

•    Collaborate with various teams to ensure testing efforts align with system deliveries and business processes.

•    Preparing PBM Statistics and Reporting.

•    Attend / Participate in the Gainwell Technologies (GWT) National Pharmacy Team Meeting.

•    Generate reports/track reporting.

•    Identify product improvements and submit Change Requests.

•    Troubleshoot complex claims issues.

•    Subject matter expert on projects that directly impact the PBM practice.

•    Collaborate with product engineers on new product enhancements.
•    Designing and developing test plans and coordinate user acceptance testing.
•    Collaborate with product engineers to troubleshoot system issues.
•    Develop training materials for PBM practice staff.
•    Conduct data drill down to identify best strategic practices.
•    Create policy and procedure documentation.

What we're looking for

•    Previous PBM experience and/or experience working in Medicaid or Medicare environments

•    Knowledge of First Data Bank drug files and hierarchy preferred 

•    Knowledge of Pharmacy Drug rebate preferred

•    Must be knowledgeable of pharmacy claims data, formats and restrictions including but not limited to NCPDP standards

•    Experience with Microsoft SQL/Oracle

•    Experience in performing pharmacy updates including benefit plan design, edit/audit set up, utilization controls, PDL, configuration updates, and auto prior authorization parameters

•    PBM Configuration experience and/or claims configuration

•    Experience identifying patterns within quantitative data, drawing conclusions, and recommending solutions and approaches, skilled with end-to-end issue resolution

•    Knowledge of computer programming concepts such as rule-based configuration, development

•    Advanced knowledge in Microsoft Excel and other software for conducting quantitative analysis 

•    Strong analytical and business policy administration skills, as well as quality testing experience

•    Strong written and oral communication and presentation skills to deliver messages to business leaders, clients, and technical personnel

•    Utilize your ability to manage multiple assignments while maintaining quality standards and meeting assigned deadlines

•    Ability to work independently and as part of a team

What you should expect in this role

•    Fully remote opportunity from most US locations

•    Opportunities to travel through your work (0-10%)

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