Senior Business Analyst - Pharmacy Management; PBM

Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at Gainwell carries its rewards. You'll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You'll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance.

We also have comprehensive leadership and technical development academies to help build your skills and capabilities.

As a Senior Business Analyst - Pharmacy Benefit Management (PBM) 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.

• Lead requirements gathering sessions with business stakeholders, SMEs, and cross-functional teams.
• Translate business needs into detailed Business Requirements Documents (BRDs), Functional Requirements Documents (FRDs), user stories, process flows, and data mappings.
• Analyze and document current and future-state workflows within PBM operations.
• Demonstrate strong knowledge of the pharmacy claims adjudication lifecycle, including:
  • Member eligibility validation
  • Formulary checks
  • Benefit plan design
  • Prior authorization
  • DUR (Drug Utilization Review)
  • Copay/coinsurance calculation
  • Rejections and overrides
• Work closely with IT teams to support system enhancements, integrations, and defect resolution.
• Participate in system design discussions and provide functional guidance to developers.
• Support EDI transactions including NCPDP standards
• your role continued
• Create test plans, test cases, and support SIT/UAT activities.
• Perform data analysis using SQL or similar tools to validate requirements and results.
• Ensure compliance with regulatory requirements (CMS, HIPAA).
• Identify process improvement opportunities and recommend solutions.

• 5+ years of experience as a Business Analyst in a PBM environment.
• Strong understanding of PBM operations and pharmacy claims adjudication.
• Experience with Medicaid plans.
• Proven experience gathering and documenting detailed business and functional requirements.
• Familiarity with NCPDP standards and EDI transactions.
• Strong analytical and problem-solving skills.
• Experience working in Agile, Scrum, or Waterfall environments.
• Excellent communication and stakeholder management skills.

• Basic to intermediate SQL for data validation and analysis.
• Familiarity with APIs, system integrations, and data mapping.
• Understanding of system architecture and data flow diagrams

• Strong attention to detail
• Ability to manage multiple priorities
• Excellent documentation and presentation skills
• Ability to bridge communication between business and technical teams
• Proactive and solution-oriented mindset

• Fully remote options from most US locations only
• Office hours: 8a-5p central required, occasional after hours may be needed.
• Video cameras must be used during all interviews, as well as during the initial week of orientation
• The deadline to submit applications for this posting has been extended until a suitable candidate is selected

The pay range for this position is $69,400.00 - $99,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work 'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance.

We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You'll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines "wages"…