PBM Specialist

Pharmacy Benefit Administration/Management(PBA/PBM) Subject Matter Expert –
Remote work with some travel - 10%
US Citizens or Permanent Residents

JOB OVERVIEW
 
The PBA/PBM (SME) is responsible for supporting numerous aspects of the design, development and implementation (DDI) followed by maintenance and operations (M&O) of a new PBAmodule as part of Medicaid Enterprise System (MES) Modernization Program. This role provides support for all aspects of the PBA effort with the emphasis on ensuring all business requirements are met, all business processes are established and the new PBAmodule is successfully integrated with all components of State.
 
The PBA/PBM SME will work with various team members, stakeholders, vendors and the provider community to ensure successful delivery aligned with CMS and State requirements, funding rules, and State priorities.  The role works closely with the current operations staff, the PBA Vendor, State Associate Director, Pharmacy Manager, State Contract Lead and other team members supporting thesuccessful implementation of the new PBA Module. The PBA/PBM SME will operate under the direction of the State Associate Director during DDI and the Medicaid Manager during M&O. 
 
 
Key RESPONSIBILITIES
Experience with PBA, PBR, FWA, and PCM.
• Utilize strong Medicaid PBA processing knowledgeto support the Project Manager inguiding/driving the DDI.
• Utilize vast historical PBA/PBM knowledge to lead discussions.
• Provide PBA/PBM expertise on all aspects of the DDI and M&O efforts.
• Review all PBA deliverables and ensure requirements are met in conjunction with the Project Manager.
• Provide subject matter expertise in Pharmacy Benefit Administration orManagement(PBA/PBM), including cost avoidance strategies and pharmacy transparency dashboards, and collaborate with the DDI vendor to design and implement these capabilities.
• Support cross-module planning to address data integration, shared services, and enterprise alignment.
• Assist in facilitating cross team partnership to ensure interoperability and architectural consistency.
• Support the testing efforts to ensure compliance.
• Provide management recommendations throughout the project.
• Identify issues and escalate as appropriate.  
• Ensure certification outcomes are clearly identifiedand addressed through all stages of the DDI.
• Support CMS certification processes and reviews.
• Support all OCM activities  
• Support all internal stakeholder activities.
 
 
REQUIRED SKILLS AND EXPERIENCE
Qualifications
Required:
• Bachelor’s degree in Business, Public Administration, a related field or comparable work experience.
• Strong understanding of Medicaid programs and CMS oversight.
• Minimum of six years of extensive PBA or PBMexperience.
• Experience with engaging large stakeholder groups.
• Excellent organization, analytic and communication skills.
 
Preferred:
 
• Experience with State Medicaid modernization initiatives.
• Experience with engaging with the Medicaid Provider Community.
• Familiarity with CMS MITA framework and APD/CPR processes.
• Familiarity with Gainwell’s MMIS system