Pharmacy Benefits Operations Consultant

KAI Partners, Inc.•Roseville, CA

2d•$142,000 - $166,000

About The Position

KAI Partners, Inc. (KAIP) is currently seeking a Pharmacy Benefits Operation Consultant who will serve as a pharmacy benefits, California Children’s Services (CCS), and Coordination of Benefits (COB) liaison supporting pharmacy benefit delivery, reporting, operational alignment, and issue resolution across project, program, and managed care stakeholders. This role will support work under Pharmacy Benefits Division leadership and will be responsible for coordinating project reporting, analyzing operational impacts, and helping resolve pharmacy benefit issues involving CCS, Medicare, Medicare Advantage, Medi-Cal, managed care plans, and related benefit programs. The Pharmacist Consultant will evaluate clinical and operational pharmacy initiatives, analyze performance and utilization data, interpret regulatory impacts, and translate findings into actionable recommendations for leadership and stakeholders. This individual will play a critical role in ensuring that pharmacy programs align with federal and state regulations, CMS guidance, and evolving healthcare legislation.

Requirements

Strong relationship-building and stakeholder management skills, with the ability to serve as a trusted liaison across pharmacy, CCS, Medicaid/Medi-Cal, Medicare, managed care, PBM operations, technical teams, vendors, and executive leadership.
Excellent verbal and written communication skills, including the ability to translate complex pharmacy benefit, Coordination of Benefits (COB), claims processing, Medicare, managed care, regulatory, and technical concepts into clear business language.
Strong facilitation and collaboration skills, with the ability to lead meetings, reconcile competing viewpoints, document decisions, build consensus, and drive issue resolution and follow-up actions.
Demonstrated knowledge of Coordination of Benefits (COB), including payer responsibility determination, eligibility conflicts, payer hierarchy, claims routing, Medicare and Medicare Advantage coordination, and operational issue resolution.
Knowledge of pharmacy benefit management (PBM) operations, including claims adjudication, business rule validation, benefit administration, implementation readiness, operational workflows, CMS reporting, and state healthcare program requirements.
Familiarity with Medi-Cal, Medicaid, Medicare, Medicare Advantage, California Children’s Services (CCS), managed care plans, CMS regulations, and related government healthcare programs.
Strong analytical, problem-solving, and critical-thinking skills, with the ability to evaluate payer responsibility, claims issues, reporting gaps, operational conflicts, system impacts, business rules, and regulatory requirements.
Ability to synthesize complex regulatory, legislative, contractual, and operational requirements into actionable business processes and operational recommendations.
Experience working with healthcare technology platforms, including PBM systems, MMIS, eligibility systems, claims processing platforms, reporting tools, and other managed care operational systems.
High degree of professionalism, discretion, and sound judgment when handling sensitive healthcare, claims, financial, regulatory, and stakeholder information.
Ability to manage conflict constructively, particularly when responsibilities overlap among managed care divisions, PBM operations, CCS programs, Medicare-related functions, and external partners.
Comfortable working in ambiguous and evolving environments while maintaining accountability, organization, structure, and forward momentum.
Detail-oriented and highly organized, with strong documentation, reporting, issue tracking, risk management, and follow-through skills.
Proven ability to manage multiple priorities, meetings, projects, reports, and issue-resolution activities in a fast-paced healthcare or government program environment.
Customer-focused, collaborative, and solutions-oriented, with a commitment to delivering effective outcomes for members, providers, health plans, government agencies, and other stakeholders.
Able to work independently under general direction while appropriately escalating risks, barriers, decisions, and compliance concerns.
Flexible and adaptable, with the ability to contribute effectively in roles such as healthcare analyst, COB specialist, PBM operations consultant, managed care liaison, pharmacist, pharmacy technician, project coordinator, or project manager based on organizational needs.
Bachelor’s degree in Pharmacy, Health Administration, Public Health, Business, Information Systems, Healthcare Management, or related field preferred; equivalent experience may substitute.
5–8 years of experience in healthcare operations, pharmacy benefits, PBM operations, Medicaid/Medi-Cal, Medicare/Medicare Advantage, managed care, COB, or government healthcare consulting.
3–5 years of experience in business analysis, project coordination/management, reporting, stakeholder engagement, or healthcare operations support.
Experience in analyst, consultant, liaison, specialist, or project coordination roles supporting healthcare operations, payer coordination, or pharmacy benefit programs.

Nice To Haves

Professional certifications such as Pharmacist licensure, CPhT, PMP, CSM, or similar are preferred but not required.
Prior experience in a role similar to a COB specialist, PBM operations consultant, pharmacy benefits analyst, managed care liaison, pharmacy technician lead, pharmacist consultant, or healthcare project manager is preferred.

Responsibilities

Serve as a liaison for pharmacy benefit operations, supporting coordination between stakeholders, Pharmacy Benefits Division leadership, managed care teams, vendors, and project resources.
Work under the direction of Pharmacy Benefits Division leadership to support pharmacy benefit initiatives, reporting needs, and operational issue resolution.
Perform project reporting responsibilities, including status updates, issue logs, risk tracking, decision tracking, action items, milestone reporting, and executive-level summaries.
Serve as a Coordination of Benefits specialist, helping identify, research, document, and resolve benefit coordination issues involving Medi-Cal, Medicare, Medicare Advantage, managed care plans, and other payer relationships.
Apply Medicare and Medicare Advantage knowledge to support pharmacy benefit coordination, claims routing, payer responsibility analysis, and operational problem-solving.
Support resolution of conflicts between managed care division processes, PBM operations, CCS requirements, and program policy expectations.
Analyze pharmacy benefit issues involving claims adjudication, business rules, eligibility, payer hierarchy, COB logic, and post-implementation outcomes.
Review and interpret reports, claims data, operational findings, and stakeholder input to identify trends, risks, gaps, and recommended actions.
Collaborate with PBM, pharmacy, managed care, CCS, IT, business operations, compliance, and project teams to align expectations and resolve cross-functional issues.
Document business processes, requirements, decisions, operational workflows, reporting needs, and issue-resolution outcomes.
Facilitate meetings and working sessions with internal teams, client stakeholders, vendors, and subject matter experts to gather information and drive next steps.
Support validation of pharmacy business rules, claims processing logic, COB-related scenarios, and implementation readiness activities.
Assist with user acceptance testing, functional testing, issue validation, and post-implementation monitoring related to pharmacy benefits and COB processes.
Provide clear, actionable recommendations to project managers, leadership, and operational stakeholders to support informed decision-making.
Monitor project timelines, deliverables, risks, dependencies, and escalations to ensure accountability and transparency.
Ensure work aligns with applicable healthcare program requirements, including CMS guidance, state requirements, HIPAA, Medi-Cal, Medicare, Medicare Advantage, and CCS-related expectations.
Perform additional duties as assigned to support pharmacy benefit operations, project success, and client service delivery.
Perform other duties, as assigned.