As part of MITRE's Center for Transforming Health, the CMS Programs Division is responsible for managing work shaping, engagement, and end-to-end delivery for the Health FFRDC's CMS Portfolio with the Centers for Medicare & Medicaid and Services (CMS).This position will contribute deep payer and pharmacy benefit manager (PBM) industry expertise to work involving prescription drug pricing, healthcare price transparency, and the development of standards and guidance for machine-readable healthcare data.

Roles & Responsibilities:

In this role, you will serve as a senior analyst and healthcare industry subject-matter expert, supporting multidisciplinary teams working at the intersection of healthcare policy, prescription drug pricing, data, and technology. You will bring deep knowledge of health plan and pharmacy benefit manager (PBM) business models, contracting, operations, and regulatory requirements to inform the development of policy, data standards, data architecture, and implementation guidance. One key focus of the role will be ensuring that proposed requirements for prescription drug pricing and negotiated-rate data reflect the operational realities of payer-to-PMB relationships, and result in pricing disclosures that can be meaningfully standardized, interpreted, and used. Another key focus will be providing clarity to plans and issuers on emerging prescription drug related data architecture and data standards.

Key Responsibilities:

• Provide senior subject-matter expertise on health plan and PBM business models, operations, contracting practices, prescription drug benefit administration, and the regulatory and policy environment affecting payer-PBM relationships.
• Advise multidisciplinary teams developing policy, standards, data architecture, and implementation guidance for prescription drug pricing and negotiated-rate information, including information reported through machine-readable files.
• Translate complex payer and PBM business processes, contractual arrangements, data flows, and operational practices into clear business and functional requirements that inform data standards, architecture, and technical guidance.
• Assess proposed policy, data, and technical requirements for operational feasibility and practical utility, drawing on an understanding of how prescription drug pricing and contracting information is created, maintained, exchanged, and used in real-world payer and PBM environments.
• Evaluate which prescription drug pricing data elements and business concepts can be meaningfully standardized or abstracted across differing payer, PBM, pharmacy, and contracting arrangements; identify important limitations, exceptions, and potential implementation challenges.
• Communicate complex industry, operational, policy, and technical concepts to federal stakeholders and interdisciplinary teams through analyses, briefings, recommendations, and implementation guidance.

Basic Qualifications:

• Typically requires a minimum of 10 years of related experience with a Bachelor's degree; or 8 years and a Master's degree; or a PhD with 5 years' experience; or equivalent combination of related education and work experience.
• Significant professional experience in the healthcare industry, including experience working with or within health plans, pharmacy benefit managers (PBMs), or organizations supporting payer and pharmacy benefit operations.
• Demonstrated knowledge of prescription drug benefit administration and the operational relationships among health plans, PBMs, pharmacies, and other healthcare stakeholders.
• Demonstrated experience with healthcare business operations, including one or more areas such as pharmacy benefit operations, payer operations, contracting, client or vendor management, benefit administration, claims, or related healthcare functions.
• Demonstrated understanding of the business, operational, contractual, policy, and regulatory considerations affecting complex healthcare and PBM programs and the ability to translate those considerations into practical recommendations or requirements.
• Strong written and verbal communication skills, including demonstrated ability to communicate complex healthcare business and operational concepts to technical and non-technical audiences.
• This position requires a minimum of 3 days a week on site.

Preferred Qualifications:

• Extensive experience spanning both health plan/payer and PBM environments, with demonstrated understanding of the business, contractual, operational, and data perspectives of each.
• Broader experience in health plan/payer operations and consulting, touching on other areas of operations, systems, and compliance, outside the prescription drug benefit administration space.
• Experience with Medicare, Medicaid, Commercial, ACA, or other regulated health insurance markets, including an understanding of how federal and state policy and regulatory requirements affect payer and PBM operations.
• Familiarity with prescription drug pricing, negotiated-rate information, healthcare price transparency, machine-readable files, or related healthcare data-reporting requirements.
• Experience advising senior executives, government stakeholders, or other decision-makers on complex healthcare operational, strategic, regulatory, technology, or data issues.

This requisition requires the candidate to have a minimum of the following clearance(s):
None

This requisition requires the hired candidate to have or obtain, within one year from the date of hire, the following clearance(s):
None

Salary compensation range and midpoint:
$155,000 - $194,000 - $233,000 Annual

Work Location Type:
Onsite