About This Role
This role involves serving as a strategic advisor and analytical expert in pharmacy benefits operations. The consultant assesses business needs, interprets pharmacy benefit requirements, and delivers data-driven insights to support project success, ensuring informed decision-making and successful delivery of healthcare and pharmacy benefit initiatives.
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
Requirements
- 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
- 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
About the Company
KAI Partners, Inc. (KAIP) is currently seeking Pharmacy Benefits Operations Consultants.
