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Benefit Configuration Specialist

1 week, 6 days ago
United States
Full-time
Mid Level
QA Engineer
Quality Assurance and Testing
Apply Now
Capital Rx

Capital Rx

Capital Rx provides comprehensive health benefit management and transparent pharmacy benefit management solutions, integrating various healthcare services to support millions of plan members across diverse sectors.

Health Care Providers & Services
251-1K
Founded 2017
View All Jobs 54

Description

  • Execute end-to-end testing and validation of pharmacy benefit plan configurations across Commercial, Medicaid, Exchange, and Medicare lines of business.
  • Perform detailed implementation audits to ensure benefit setups align with client intent, regulatory requirements, and internal standards.
  • Review plan design documents, benefit change forms, and formulary specifications to build executable test scenarios.
  • Analyze claim outputs to confirm expected adjudication behavior and accumulator movement.
  • Identify, document, and communicate configuration discrepancies or defects and partner with configuration teams to resolve them.
  • Ensure compliance with applicable federal and state regulations, including CMS guidance where applicable.
  • Maintain clear documentation of testing results, audit findings, and approval signoffs.
  • Participate in client-facing meetings to review testing scope, explain findings, and clarify benefit intent.
  • Partner with cross-functional teams to support benefit accuracy and successful implementation.
  • Contribute to process improvements that increase testing efficiency, audit quality, and benefit validation standards.

Requirements

  • Bachelor’s degree in Healthcare Administration, Business, Information Systems, or a related field, or equivalent work experience.
  • 3–5 years of experience in pharmacy benefit management (PBM), health plan operations, or benefit configuration.
  • Direct experience supporting Medicare lines of business, including Medicare Part D and/or MAPD.
  • Demonstrated understanding of Medicare benefit structures.
  • Experience testing and validating pharmacy benefit configurations across Commercial, Medicaid, Exchange, and/or Medicare lines of business.
  • Strong knowledge of formulary design, tier structures, utilization management (PA, ST, QL), and accumulator logic.
  • Ability to analyze benefit design documents and translate requirements into executable test scenarios.
  • Strong analytical skills with high attention to detail and accuracy.
  • Proficiency in Microsoft Excel for data review, validation, and reporting.
  • Strong written and verbal communication skills with the ability to document findings, discrepancies, and testing outcomes clearly.

Benefits

  • Medical and pharmacy coverage, dental insurance, and vision insurance.
  • Accidental injury, critical illness, and hospital indemnity insurance, plus flexible spending accounts.
  • Health savings account, voluntary life insurance, and voluntary AD&D coverage for full-time employees and eligible dependents.
  • Free basic life insurance and basic AD&D insurance for full-time employees.
  • Paid time off, sick time, and company holidays.
  • Short-term disability, long-term disability, and an employee assistance program.
  • Wellness program provided at no cost to full-time employees.
  • 401(k) plan with company match after one year of full-time employment.

Interested in this position?

Apply directly on the company website

Apply Now

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