PBM System Specialist

Job Title

Location

Employment Type

Job Summary

Key Responsibilities

1. Code Management

   :
• Review, validate, and add new drug codes from the various sources to the master drug database.
• Ensure timely and accurate updates to the tariff to support claims processing and reimbursement accuracy.

2. Clinical Review

   :
• Evaluate medical necessity, drug interactions, and contraindications to ensure safe and effective patient care.

3. Audit and Compliance

   :
• Monitor hospital and provider submissions to identify and prevent tariff abuse, such as the use of generic codes instead of dedicated pharmacy codes.
• Ensure masters and system validation are in sync with regulatory requirements.

4. Trend Analysis

   :
• Analyse drug consumption patterns and system usage trends to identify opportunities for cost savings, process improvements, and formulary optimization.
• Generate reports to support strategic decision-making.

5. Tariff Updates

   :
• Conduct periodic reviews of tariff structures, incorporating geographic, market, and economic factors.
• Recommend and implement updates to ensure competitive and equitable pricing.

6. FHIR Standard Support

   :
• Support the mapping and integration of the PBM system to comply with Fast Healthcare Interoperability Resources (FHIR) standards.
• Assist in implementing interoperable data exchange solutions to enhance system connectivity with other healthcare platforms.

7. Data Analysis and Reporting

   :
• Perform data analysis to provide actionable insights for business and clinical stakeholders.
• Utilize analytics tools to support PBM system performance and operational efficiency.

Qualifications

• Bachelor’s degree in pharmacy, or MBBS doctor healthcare administration, health informatics, or a related field.
• Strong knowledge of pharmacy benefit management systems and processes.
• Experience with healthcare coding systems, including National Drug Codes (NDC), J-Codes, and Healthcare Common Procedure Coding System (HCPCS).
• Exceptional analytical and problem-solving skills with a keen attention to detail.
• Ability to thrive in a fast-paced environment while maintaining accuracy and precision.
• Excellent communication and stakeholder management skills to collaborate with internal teams, providers, and payers.

Preferred

• Advanced degree or certification in pharmacy, health informatics, or a related field.
• Prior experience in a pharmacy or healthcare setting, such as a pharmacy technician or clinical analyst role.
• Familiarity with FHIR standards and healthcare data interoperability.
• Proficiency in data analytics tools (e.g., Tableau, Power BI, SQL) or reporting software.
• Knowledge of regulatory compliance in pharmacy benefit management (e.g., CMS, HIPAA).

Key Competencies

• Analytical thinking and data interpretation.
• Attention to detail and organizational skills.

Role & responsibilities

Preferred candidate profile