Manager, Benefit Design – Requirements

This is a fully remote position, open to applicants in Kentucky.

📋 Description

• Act as the main subject matter expert and trusted advisor for clients, both new and existing, during the implementation lifecycle and ongoing benefit modifications, guiding them from the initial benefit design to a validated go-live.

• Facilitate structured discovery sessions with clients and consultants across various functions to document plan-level intentions, formulary structures, cost-sharing logic, accumulator rules, specialty tier design, step therapy protocols, and coverage gap parameters.

• Proactively identify gaps in the documentation provided by clients; collaborate directly with the implementation lead or client manager to address issues before the build phase, minimizing downstream risks.

• Advise clients on industry best practices, the capabilities of the AffirmedRx platform, and key implementation considerations to empower them to make informed decisions regarding benefit design.

• Convert intricate PBM benefit configurations into clear and comprehensive benefit requirement documents that serve as the definitive source of truth for the build team.

• Maintain traceability of requirements throughout the project lifecycle; ensure that any scope changes are recorded, communicated, and incorporated into all downstream deliverables.

• Develop and consistently enhance standardized requirement templates, intake frameworks, and documentation standards that are scalable across client engagements.

• Collaborate with Implementation Managers, vendors, TPAs, and clinical operations to guarantee complete alignment between documented requirements and system configurations.

• Utilize hands-on benefit build knowledge to assess configured plans in the AffirmedRx adjudication system, ensuring that the build accurately mirrors approved requirements prior to testing.

• Serve as a resource for internal Implementation team members regarding PBM benefits, plan design logic, and configuration best practices.

• Identify build discrepancies early by leveraging a deep understanding of how benefit rules translate into adjudication logic.

• Review and confirm end-to-end benefit testing results generated by the adjudication partner, ensuring that plan rules, cost-sharing logic, accumulator behavior, and compliance checkpoints align exactly with approved requirements.

• Detect gaps in test coverage and request additional scenarios from the adjudication partner to rigorously test custom scenarios, benefit interactions, and complex plan configurations.

• Lead User Acceptance Testing (UAT) cycles in collaboration with RxSense and internal teams; manage defect logging, resolution tracking, and confirmation of remediation.

• Provide comprehensive go-live readiness reports that summarize testing outcomes, outstanding items, and risk assessments.

• Develop, standardize, and continuously refine templates for requirements documentation, test plans, test scripts, and defect tracking.

• Assist in audit and compliance activities by ensuring all documentation adheres to regulatory and contractual standards.

• Participate in post-implementation retrospectives, identifying recurring issues and suggesting systemic enhancements.

• As the function scales, engage in the hiring, onboarding, and development of analysts.

⛳️ Requirements

• Over 5 years of experience in pharmacy benefit management (PBM), health plan, or specialty pharmacy operations with direct involvement in benefit configuration or plan design.

• Bachelor’s degree in Business Administration, Healthcare Administration, Health Informatics, Pharmacy, or a related field.

• Proven expertise in interpreting and translating PBM benefit structures—including formularies, prior authorization, step therapy, accumulators, and cost-sharing designs—into system-ready requirements.

• Demonstrated experience in designing and executing benefit or claims testing within managed care, PBM, or pharmacy technology environments.

• Outstanding written communication skills with the capability to produce clear and detailed requirements and testing documentation.

• Strong client-facing consultative skills; adept at building rapport, asking probing questions, and managing competing stakeholder expectations professionally.

• High analytical aptitude and comfort with ambiguity; able to synthesize complex and inconsistent source material into clear, actionable deliverables.

• A builder’s mindset—motivated by the prospect of creating something from the ground up and driven by the opportunity to establish a function that others will develop within.

• Familiarity with regulatory frameworks governing pharmacy benefits (e.g., CMS guidelines, ACA compliance, ERISA) is preferred.

• Hands-on experience in building or configuring benefits within a PBM or pharmacy adjudication platform is highly advantageous.

• Willingness to travel up to 25% of the time.

🏝️ Benefits

• Opportunity to influence industry change in the pharmacy benefits management sector while delivering the highest quality patient outcomes.

• Work within a culture that fosters individual growth, as the success of our team directly contributes to the success of our business.

• Competitive compensation package, including health, dental, vision, and other benefits.