Pharmacy Benefits Operations Consultant

KAI Partners, Inc.; Roseville (CA); Sur place; USD 120 000 - 150 000; Plein temps

Résumé du poste

KAI Partners, Inc. is seeking Pharmacy Benefits Operations Consultants to serve as strategic advisors and analytical experts, responsible for assessing business needs, interpreting PBM requirements, and delivering data-driven insights that support project success.

They conduct in-depth business and data analysis, request and evaluate reports, and synthesize findings into actionable conclusions. Consultants may also coordinate validation of pharmacy business rules and claims adjudication

Qualifications

• Bachelor’s degree in health administration, public health, or a related field is required.
• PM/CSM and pharmacy background are preferred.
• Experience with PBM operations, claims processing, and CMS/state reporting is expected.

Responsabilités

• Apply expert PBM knowledge to validate business rules, claims processing, and implementation readiness.
• Assess federal and state funding implications, align with CMS reporting and compliance.
• Conduct detailed business analysis to document needs, goals, and system requirements.
• Collaborate cross-functionally with IT, operations, pharmacy, and healthcare staff.

Connaissances

PBM knowledge

Analytical skills

Communication skills

Stakeholder management

Cross-functional collaboration

Formation

Bachelor’s degree in Health Administration, Public Health, Business Administration, Information Systems, Pharmacy, or related field

Master’s degree (MPH, MBA, MHA, or related discipline)

PMP or Certified Scrum Master (CSM)

Pharmacy Technician Certification (CPhT) or pharmacy background

Outils

MMIS

PBM platforms

Claims processing

Description du poste

Pharmacy Benefits Operation Consultant

KAI Partners, Inc. (KAIP) is currently seeking Pharmacy Benefits Operations Consultants to serve as strategic advisors and analytical experts, responsible for assessing business needs, interpreting pharmacy benefit requirements, and delivering data-driven insights that support project success. They conduct in-depth business and data analysis, request and evaluate reports, and synthesize findings into actionable conclusions. Consultants may also coordinate validation of pharmacy business rules and claims adjudication processes, review test cases, and confirm that proper post-implementation reports are designed to highlight issues after deployment. Additional responsibilities include maintaining project schedules, managing tasks and risks, and ensuring readiness for implementation. Through clear documentation, cross-functional collaboration, and stakeholder communication, consultants enable informed decision-making and contribute to the successful delivery of healthcare and pharmacy benefit initiatives.

Responsibilities

• Apply expert knowledge of pharmacy benefit management (PBM) to support the validation of business rules, claims processing, adjudication logic, test case review, and implementation readiness assessments.


• Assess the implications of federal and state funding and ensure accurate alignment with CMS reporting and compliance standards.


• Conduct detailed business analysis to identify, document, and prioritize project needs, goals, business processes, and system requirements.


• Collaborate cross-functionally with IT, operations, pharmacy, and healthcare staff to ensure successful execution of project deliverables.


• Analyze, interpret, and translate complex pharmacy benefit requirements into functional specifications for systems and teams.


• Ensure adherence to applicable federal and state regulations, including HIPAA, CMS guidelines, and other healthcare regulatory frameworks.


• Identify, track, and report project issues, risks, and mitigation strategies, ensuring stakeholders are informed and aligned.


• Facilitate and lead stakeholder requirements-gathering sessions to capture comprehensive business and technical needs.


• Monitor project timelines, track tasks and dependencies, and communicate status updates to ensure transparency and accountability.


• Conduct user acceptance testing (UAT), functional testing, and quality assurance (QA) to validate solution integrity and identify issues.


• Evaluate pharmacy benefit performance metrics and make data-driven recommendations to improve outcomes and operational efficiency.


• Provide clear, actionable insights to project managers and leadership to support informed decision-making and project alignment.


• Comply with KAI Partners’ quality management processes, professional conduct standards, and ethical guidelines while demonstrating discretion and independent judgment.


• Log work hours accurately and promptly in designated systems to meet internal and client compliance and reporting requirements.


• Commit to continuous learning and development of new technologies, methodologies, and industry best practices to enhance organizational and client success.


• Perform other duties, as assigned.

Skills and Qualifications

• Demonstrate excellent verbal and written communication skills, effectively engaging with both internal and external customers.


• Strong analytical, critical thinking, and problem-solving skills.


• Confidently present data and insights to clients, delivering clear and impactful messaging.


• Exhibit a driven, self-starting mindset with strong abilities in customer engagement, communication, influence, leadership, and critical thinking.


• Maintain composure under pressure, meet deadlines with a positive attitude and exemplary customer service.


• Work independently to complete assignments within guidelines, prescribed routines, and standard practices under general supervision.


• Adhere to all company policies, procedures, and compliance requirements.


• Thrive in a fast-paced, dynamic environment by managing multiple tasks, deliverables, and projects with minimal supervision.

Work/Education Experience

• Bachelor’s degree in Health Administration, Public Health, Business Administration, Information Systems, Pharmacy, or a related field. (Required)


• Master’s degree (MPH, MBA, MHA, or related discipline) (Preferred)


• Project Management Professional (PMP) or Certified Scrum Master (CSM) (Preferred)


• Pharmacy Technician Certification (CPhT) or relevant pharmacy background.


• 5–8 years of relevant experience in healthcare, pharmacy benefits, or Medicaid/Medicare consulting environments.


• Demonstrated experience supporting PBM operations, including:
  
  
  
  • Claims processing and adjudication
  
  
  • Business rule validation
  
  
  • CMS and state reporting
  
  
  • Implementation readiness and compliance
  
  
  
  


• Three to five years of hands‑on experience in business analysis, including requirements gathering, documentation, stakeholder facilitation, and use case development.


• Experience working with state or federal healthcare programs (e.g., Medi-Cal, Medicaid, Medicare, CMS regulations) is strongly preferred.


• Experience with health IT systems such as pharmacy benefit platforms, MMIS, or claims processing systems.


• Proven ability to collaborate in cross-functional teams, interact with technical and non-technical stakeholders, and drive forward complex healthcare initiatives.

Compensation Range:

$120,000 - $150,000

The salary range for this role may vary depending on the specific geographic location where this position is ultimately filled. Several factors, including but not limited to a candidate's experience, education, skills, and certifications, pay equity, and organizational needs, are considered when determining the posted salary range. In addition, eligible roles also qualify for a comprehensive benefits package.

Must be able to provide proof of education for all mandatory qualifications; all references will be verified.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

KAI Partners

KAI Partners, Inc. is a Northern California-based small business that offers world-class management consulting and technology services to public and private sector clients on a variety of large-scale projects. The KAI Partners team has over 100 years of combined executive-level experience in information system design, development, implementation, and testing. Our clients benefit from our proven program management, project management, and oversight, program portfolio management, Agile services, organizational change management, training, enterprise architecture, managed IT service, and IT security support.

http://www.kaipartners.com/