Senior Business Analyst - Pharmacy Benefit 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.

Summary

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.

We are seeking a detail-oriented and experienced Senior Business Analyst (Sr. BA) with 5+ years of experience in Pharmacy Benefit Management (PBM). The ideal candidate will have strong client facing experience with expertise in requirements gathering, documentation, and a deep understanding of the pharmacy claims adjudication process. This role requires collaboration with business stakeholders and technical teams to deliver high-quality solutions that support PBM operations.

Your role in our mission

• 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.

What we're looking for

• 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.

Technical skills (preferred)

• 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

Soft skills

• 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

What you should expect in this role

• 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