Pharmacy Benefits Operations Consultant

KAI Partners, Inc.•Roseville, CA

7d•$120,000 - $150,000

About The Position

KAI Partners, Inc. (KAIP) is currently seeking Pharmacy Benefits Operations Consultants to serve as strategic advisors and analytical experts, responsible for assessing business needs, interpreting pharmacy benefit requirements, and delivering data-driven insights that support project success. They conduct in-depth business and data analysis, request and evaluate reports, and synthesize findings into actionable conclusions. Consultants may also coordinate validation of pharmacy business rules and claims adjudication processes, review test cases, and confirm that proper post-implementation reports are designed to highlight issues after deployment. Additional responsibilities include maintaining project schedules, managing tasks and risks, and ensuring readiness for implementation. Through clear documentation, cross-functional collaboration, and stakeholder communication, consultants enable informed decision-making and contribute to the successful delivery of healthcare and pharmacy benefit initiatives.

Requirements

Demonstrate excellent verbal and written communication skills, effectively engaging with both internal and external customers.
Strong analytical, critical thinking, and problem-solving skills.
Confidently present data and insights to clients, delivering clear and impactful messaging.
Exhibit a driven, self-starting mindset with strong abilities in customer engagement, communication, influence, leadership, and critical thinking.
Maintain composure under pressure, meet deadlines with a positive attitude and exemplary customer service.
Work independently to complete assignments within guidelines, prescribed routines, and standard practices under general supervision.
Adhere to all company policies, procedures, and compliance requirements.
Thrive in a fast-paced, dynamic environment by managing multiple tasks, deliverables, and projects with minimal supervision.
Bachelor’s degree in Health Administration, Public Health, Business Administration, Information Systems, Pharmacy, or a related field. (Required)
5–8 years of relevant experience in healthcare, pharmacy benefits, or Medicaid/Medicare consulting environments.
Demonstrated experience supporting PBM operations, including: Claims processing and adjudication, Business rule validation, CMS and state reporting, Implementation readiness and compliance
Three to five years of hands-on experience in business analysis, including requirements gathering, documentation, stakeholder facilitation, and use case development.
Proven ability to collaborate in cross-functional teams, interact with technical and non-technical stakeholders, and drive forward complex healthcare initiatives.

Nice To Haves

Master’s degree (MPH, MBA, MHA, or related discipline) (Preferred)
Project Management Professional (PMP) or Certified Scrum Master (CSM) (Preferred)
Pharmacy Technician Certification (CPhT) or relevant pharmacy background.
Experience working with state or federal healthcare programs (e.g., Medi-Cal, Medicaid, Medicare, CMS regulations) is strongly preferred.
Experience with health IT systems such as pharmacy benefit platforms, MMIS, or claims processing systems.

Responsibilities

Apply expert knowledge of pharmacy benefit management (PBM) to support the validation of business rules, claims processing, adjudication logic, test case review, and implementation readiness assessments.
Assess the implications of federal and state funding and ensure accurate alignment with CMS reporting and compliance standards.
Conduct detailed business analysis to identify, document, and prioritize project needs, goals, business processes, and system requirements.
Collaborate cross-functionally with IT, operations, pharmacy, and healthcare staff to ensure successful execution of project deliverables.
Analyze, interpret, and translate complex pharmacy benefit requirements into functional specifications for systems and teams.
Ensure adherence to applicable federal and state regulations, including HIPAA, CMS guidelines, and other healthcare regulatory frameworks.
Identify, track, and report project issues, risks, and mitigation strategies, ensuring stakeholders are informed and aligned.
Facilitate and lead stakeholder requirements-gathering sessions to capture comprehensive business and technical needs.
Monitor project timelines, track tasks and dependencies, and communicate status updates to ensure transparency and accountability.
Conduct user acceptance testing (UAT), functional testing, and quality assurance (QA) to validate solution integrity and identify issues.
Evaluate pharmacy benefit performance metrics and make data-driven recommendations to improve outcomes and operational efficiency.
Provide clear, actionable insights to project managers and leadership to support informed decision-making and project alignment.
Comply with KAI Partners’ quality management processes, professional conduct standards, and ethical guidelines while demonstrating discretion and independent judgment.
Log work hours accurately and promptly in designated systems to meet internal and client compliance and reporting requirements.
Commit to continuous learning and development of new technologies, methodologies, and industry best practices to enhance organizational and client success.
Perform other duties, as assigned.