SummaryThe PBM Implementation Pharmacist reports to the Director of Clinical Operations and leads the clinical setup of new Pharmacy Benefit Management (PBM) accounts from both system and functional perspectives. This role serves as the subject matter expert for pharmacy services, including benefit plan drug coverage, edit configuration, prospective and retrospective drug utilization review (DUR), prior authorization (PA) criteria and rule configuration, and coordination with the implementation practice team to support successful program implementation for customer organizations.
Essential Functions may include: - Serve as the primary clinical SME on pharmacy implementations
- Lead clinical and drug reference domains on pharmacy design, development, and implementations (DDIs)
- Be a primary point of contact with the state client pharmacy team during the DDI and hypercare phases
- Ensure benefit plan drug coverages are configured accurately to state client specifications and requirements
- Validate successful and accurate conversion of pharmacy data from other vendors and stakeholders
- Ensure all point-of-sale (POS) claims processing edits, pricing, return messaging, and configuration meet the business requirements of the client
- Work with engineering and pharmacy business analyst teams to configure automated PA rule sets and electronic prior authorization (EPA) question sets, including testing scenarios and validation with the client
- Track and document progress of clinical domain activities against requirements and timelines, and provide status reports to senior leaders
- Identify risks or issues, ensure they are documented and tracked, and work with appropriate stakeholders to resolve them
- Maintain a clear understanding of the operational readiness, certification, and delivery status of all Gainwell pharmacy implementations
- Provide subject matter expertise for pharmacy and drug rebate product development, sales pursuits, RFP responses, and DDIs
- Encourage and strengthen cohesiveness and team unity across the pharmacy business and stakeholders on all Gainwell pharmacy implementations • Participate in corporate pharmacy team meetings
Experience:- Active pharmacist license is required
- Minimum of five (5) years of experience in pharmacy benefit management
- Minimum of three (3) years of experience working with a Medicaid PBM account
- Detailed knowledge of Medicaid at the state and federal level
- Experience and knowledge of NCPDP standards and point-of-sale (POS) pharmacy claim processing is required
- Experience and knowledge of First Databank (FDB) drug hierarchies, drug reference files, and prospective DUR parameters is required; understanding of Medispan hierarchies is preferred
Knowledge, Skills, Abilities: - PBM or managed care pharmaceutical service experience preferred
- Proficient PC abilities (basic knowledge of MS Office applications), work organization, and problem-resolution skills, including the ability to learn configuration activities in a PBM database and other technical tools
- Proficient on multiple virtual communication platforms (Microsoft Teams, Skype, Zoom, etc.)
- Ability to communicate succinctly and accurately in both written and verbal English in various group settings
- Strong leadership abilities demonstrating proactive initiative
- Analytical skills that translate into practical and pragmatic recommendations
- Ability to work independently and in a team environment
- Ability to work effectively and efficiently under stringent timelines
- Excellent organizational, written, and oral communication skills
- Ability to maintain confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA)
What to Expect- Fully remote position within the U.S.
- 0-10% travel
Applications for this posting will be accepted until July 30, 2026.
The pay range for this position is $113,700.00 - $162,400.00 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 at Gainwell. You'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.
