Description

The PBM Business Integration Specialist will serve as a vital member of the DHHS Medicaid Enterprise System (MES) Program within the Pharmacy Business space. This role involves providing expertise and business support to the Pharmacy and Ancillary Services Business Unit during the development and implementation of the Medicaid Enterprise Modular Pharmacy Business Management (PBM) Solution. As a Business Subject Matter Expert, you will assist the Department in onboarding the PBM vendor and represent the Pharmacy Business Unit in the implementation of this complex and innovative solution.

The primary responsibility includes serving as the subject matter expert and content lead in collaboration with the Pharmacy Business team. Key areas of focus will be Clinical Policies, Prior Authorizations, Drug Utilization Review (DUR), pharmacy lock-in processes, Behavioral Health, A+ Kids, Preferred Drug List (PDL), Medicaid Drug Rebate Program (MDRP), and Physicians Administered Drug Program (PADP).

Compensation and Benefits

• Competitive W-2 hourly rate up to $55/hour
• Hybrid work schedule with flexibility
• Opportunity to work on impactful Medicaid initiatives

Why you should apply for this position today

This position offers a unique chance to contribute to meaningful projects within the Medicaid system, making a tangible impact on healthcare services. By joining our team, you will have the opportunity to work collaboratively with various stakeholders while being at the forefront of the Pharmacy Benefit Management solution development.

Skills

• In-depth knowledge of Medicaid Pharmacy Benefits Management processes
• Strong collaboration and communication skills
• Ability to research and recommend business initiatives
• Experience in Medicaid, managed care, and Pharmacy Benefit Manager (PBM) operations
• Proven experience in drafting business process documents and user acceptance test scenarios

Responsibilities

• Support one or more Pharmacy business process areas including:
  • Clinical policies and Prior Authorizations
  • Drug Utilization Review (DUR) and pharmacy lock-in related processes
  • Behavioral health and A+ kids
  • Preferred Drug List (PDL) and Medicaid Drug Rebate Program (MDRP)
  • Physicians Administered Drug Program (PADP) related to the Medicaid Drug Rebate Program (MDRP)
• Collaborate with PBM Business stakeholders, including Product Managers and Business Leads
• Provide feedback and strategic input to senior decision-makers
• Ensure compliance with all applicable policies and procedures
• Support the entire product lifecycle from conception through implementation
• Perform other duties as assigned

Qualifications

• Proven experience in Medicaid applications and Pharmacy Functional Areas
• Strong business acumen and understanding of healthcare business needs
• Ability to translate business owner needs into actionable requirements

Education Requirements

• Bachelor’s degree in relevant field preferred

Education Requirements Credential Category

• Healthcare or Business Management related field

Experience Requirements

• Previous experience in Medicaid and pharmacy benefits management
• Strong background in supporting complex business implementations

Why work in Raleigh, NC

Raleigh, NC, is known for its vibrant community, rich history, and continually growing job market. The city offers a unique blend of culture, education, and innovation, making it an attractive location for professionals. With a strong tech ecosystem, numerous parks, recreational opportunities, and a lively arts scene, Raleigh provides an excellent work-life balance that supports both personal and professional growth.