Business Analyst – Pharmacy Claims

What you’ll do
Gather, analyze and translate pharmacy claims workflow requirements into Business Requirements Documents (BRDs), Functional System Specifications (FSDs) and user stories with clear acceptance criteria.
Map transaction data fields across NCPDP Version F6 standards, including Eligibility Verification (E1), Claim Billing (B1), Claim Reversal (B2), Claim Rebill (B3) and Predetermination of Benefits (D1).
Analyze field-level changes between NCPDP D.0 and F6, including:
expanded field lengths (such as dollar and provider ID fields)
new segment structures
pricing and copay indicators
clinical and prescriber information fields
Assess the impact of these changes on adjudication logic, data models, payer sheets and downstream reporting.
Build traceability from business requirements through functional specs, stories and test cases. Support QA, UAT and trading partner testing.
Facilitate requirements sessions and resolve gaps or conflicts between business and technical stakeholders.
What you bring
[5+] years as a Business Analyst, with at least [3] years in pharmacy benefits, PBM, pharmacy claims processing or a related healthcare domain.
Hands-on experience with the NCPDP Telecommunication Standard (D.0 required; F6 strongly preferred), including segments, field IDs and transaction types.
Proven experience writing BRDs, FSDs and user stories in an Agile or hybrid environment.
Working knowledge of claims adjudication concepts such as eligibility, pricing, COB, DUR, reject codes and payer sheets.
Strong data analysis skills, with the ability to build field mappings and crosswalks in Excel or similar tools. SQL is a plus.
Clear written and verbal communication, and comfort working with both business and technical teams.
Nice to have
Experience with Medicare Part D (including PDE reporting), Medicaid or commercial pharmacy programs.
Exposure to NCPDP Batch Standard, payer sheet development or switch/intermediary processing.
Familiarity with JIRA, Confluence or similar tools.
Healthcare or pharmacy certifications (e.g., CPhT, AHIP or CBAP).