Remote PBM Benefit Configuration Specialist

Judi Health; Denver (CO); Hybrid; USD 72,000 - 99,000; Full time

Benefits offered by this job

Health benefits

401(k) with company match

Paid time off

Job summary

Capital Rx in New York and Denver seeks a Benefit Configuration Specialist to validate pharmacy benefit plan configurations across Commercial, Medicaid, Exchange and Medicare lines, ensuring alignment with client intent and regulatory standards.

You will analyze plan designs, review documents, perform audits, and collaborate with cross‑functional teams to ensure accurate benefit adjudication and timely resolutions. Strong PBM knowledge and Excel skills are required.

Qualifications

• Bachelor’s degree or equivalent experience in a related field.
• 3–5 years in PBM, health plan ops, or benefit configuration.
• Direct Medicare Part D/MAPD experience is preferred.
• Knowledge of formulary design, tiering, utilization management, and accumulator logic.
• Ability to translate benefit design docs into test scenarios.

Responsibilities

• Execute testing and validation of pharmacy benefit plan configurations across multiple lines of business.
• Perform audits to ensure benefit setups meet client intent, regulatory requirements, and internal standards.
• Review plan design documents and formulary specs to create executable test scenarios.
• Analyze claim outputs to confirm adjudication behavior and accumulator movement.
• Document discrepancies and collaborate with the configuration team for resolution.
• Ensure compliance with federal and state regulations, including CMS guidance where applicable.
• Maintain documentation of testing results and audit findings for client reviews.
• Participate in client meetings to review scope and testing outcomes.

Skills

Analytical skills

Detail oriented

Excel proficiency

Strong communication

Client-facing experience

Education

Bachelor’s degree in Healthcare Administration or related field

Equivalent experience in PBM or health plan operations

Tools

Microsoft Excel

Job description

Capital Rx in New York and Denver seeks a Benefit Configuration Specialist to validate pharmacy benefit plan configurations across Commercial, Medicaid, Exchange and Medicare lines, ensuring alignment with client intent and regulatory standards.

You will analyze plan designs, review documents, perform audits, and collaborate with cross‑functional teams to ensure accurate benefit adjudication and timely resolutions. Strong PBM knowledge and Excel skills are required.