Healthcare Payer PBM Business Architect

Hiring! Healthcare Payer and PBM Operations Architect - for a contract to hire job opportunity with our direct client. Though this is a 100% remote based job opportunity, we are seeking candidates that are located in the DMV, WVA, PA, NY, NJ or Texas areas. Candidates must be eligible for full time employment and work on a W2 basis.

Job requirement:

• 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.

If you have the strong PBM/Arch / Healthcare delivery skills, Select "Apply Now" and a Vega staffing specialist will reach out to you.