PBM System Specialist

4 days ago

Bengaluru, Karnataka, India Vidal Health Insurance Full time ₹ 2,50,000 - ₹ 7,50,000 per year

Job Title: PBM System Specialist

Location: Bangalore work from Office

Employment Type: Full-Time

Job Summary

We are seeking a detail-oriented and analytical Pharmacy Benefit Management (PBM) System Specialist to oversee the operation, maintenance, and optimization of our pharmacy benefit management system and masters. The PBM System Specialist will ensure the systems accuracy, compliance, and alignment with market practice. This role requires a strong understanding of pharmacy coding systems, and data interoperability standards, combined with exceptional analytical and communication skills.

Key Responsibilities

  1. Code Management:

  2. Review, validate, and add new drug codes from the various sources to the master drug database.

  3. Ensure timely and accurate updates to the tariff to support claims processing and reimbursement accuracy.

  4. Clinical Review:

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

  6. Audit and Compliance:

  7. Monitor hospital and provider submissions to identify and prevent tariff abuse, such as the use of generic codes instead of dedicated pharmacy codes.

  8. Ensure masters and system validation are in sync with regulatory requirements.

  9. Trend Analysis:

  10. Analyse drug consumption patterns and system usage trends to identify opportunities for cost savings, process improvements, and formulary optimization.

  11. Generate reports to support strategic decision-making.

  12. Tariff Updates:

  13. Conduct periodic reviews of tariff structures, incorporating geographic, market, and economic factors.

  14. Recommend and implement updates to ensure competitive and equitable pricing.

  15. FHIR Standard Support:

  16. Support the mapping and integration of the PBM system to comply with Fast Healthcare Interoperability Resources (FHIR) standards.

  17. Assist in implementing interoperable data exchange solutions to enhance system connectivity with other healthcare platforms.

  18. Data Analysis and Reporting:

  19. Perform data analysis to provide actionable insights for business and clinical stakeholders.

  20. Utilize analytics tools to support PBM system performance and operational efficiency.

Qualifications

Required:

  • 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.

Ability to manage multiple priorities and meet Role & responsibilities

Preferred candidate profile

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