Manager, Benefit Design – Requirements
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Job Description
Manager responsible for establishing PBM benefit design processes at AffirmedRx. Guiding clients from implementation to go-live while ensuring compliance and best practices.
Responsibilities:
- Serve as the primary PBM subject matter expert and trusted advisor to new and existing clients throughout the implementation lifecycle and steady state benefit changes, guiding them from initial benefit design through validated go-live
- Lead structured discovery sessions with clients and consultants cross-functionally to document plan-level intent, formulary structures, cost-sharing logic, accumulator rules, specialty tier design, step therapy protocols, and coverage gap parameters
- Proactively identify gaps in client-provided documentation; work directly with the implementation lead or client manager to resolve issues before build begins, reducing downstream risk
- Advise clients on industry best practices, AffirmedRx platform capabilities, and implementation considerations to help them make informed benefit design decisions
- Translate complex PBM benefit configurations into clear, comprehensive benefit requirement documents that serve as the authoritative source of truth for the build team
- Maintain requirement traceability throughout the lifecycle; ensuring that scope changes are captured, communicated, and reflected in all downstream deliverables
- Build and continuously improve standardized requirement templates, intake frameworks, and documentation standards that scale across client engagements
- Collaborate with Implementation Managers, vendors, TPAs, and clinical operations to ensure full alignment between documented requirements and system configuration
- Apply hands-on benefit build knowledge to review configured plans in AffirmedRx adjudication system, validating that the build accurately reflects approved requirements prior to testing
- Act as an internal resource for Implementation team members on PBM benefits, plan design logic, and configuration best practices
- Flag build discrepancies early by leveraging deep familiarity with how benefit rules translate into adjudication logic
- Review and validate end-to-end benefit testing results produced by the adjudication partner, confirming that plan rules, cost-sharing logic, accumulator behavior, and compliance checkpoints align precisely with approved requirements
- Identify gaps in test coverage and request additional scenarios from the adjudication partner to stress-test custom scenarios, benefit interactions, and complex plan configurations
- Lead UAT cycles in coordination with RxSense and internal teams; manage defect logging, resolution tracking, and remediation confirmation
- Deliver clear go-live readiness reports summarizing test outcomes, open items, and risk assessments
- Build, standardize, and continuously improve templates for requirements documentation, test plans, test scripts, and defect tracking
- Support audit and compliance activities by ensuring all documentation meets regulatory and contractual standards
- Contribute to post-implementation retrospectives, identifying recurring issues and recommending systemic improvements
- As the function scales, participate in hiring, onboarding, and developing analysts
Requirements:
- 5+ years of experience in pharmacy benefit management (PBM), health plan, or specialty pharmacy operations with direct exposure to benefit configuration or plan design
- Bachelor’s degree in Business Administration, Healthcare Administration, Health Informatics, or Pharmacy or related field
- Demonstrated expertise interpreting and translating PBM benefit structures — including formularies, prior authorization, step therapy, accumulators, and cost-sharing designs — into system-ready requirements
- Proven experience designing and executing benefit or claims testing in a managed care, PBM, or pharmacy technology environment
- Exceptional written communication skills with the ability to produce clear, detailed requirements and testing documentation
- Strong client-facing consultative skills; ability to build rapport, ask probing questions, and manage competing stakeholder expectations with professionalism
- High analytical aptitude and comfort with ambiguity; can synthesize complex, inconsistent source material into clean, actionable deliverables
- A builder’s mindset — energized by creating something from scratch and motivated by the opportunity to establish a function others will grow within
- Exposure to regulatory frameworks governing pharmacy benefits (e.g., CMS guidelines, ACA compliance, ERISA) preferred
- Hands-on experience building or configuring benefits within a PBM or pharmacy adjudication platform is a strong plus
- Willingness to travel up to 25%
Benefits:
- To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
- To work in a culture where people thrive because when OUR team thrives, OUR business thrives
- Competitive compensation, including health, dental, vision and other benefits
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