Pharmacy Test Implementation Lead

Regular

Exempt

GENERAL DESCRIPTION

Responsible for developing the test plan, conducting, and monitoring the testing of drug lists, pharmacy benefits, and medical components prior to the effective date for all company business lines. Ensures that the coding on the Pharmacy Benefit Management (PBM) adjudication platform for drug listings is accurate as specified in the implementation documents.

ESSENTIAL FUNCTIONS:

- Designs and coordinates the test plan to ensure it is aligned with the implementation process work plan as well as with the validation of the management.
- Define and create necessary test cases, along with their expected benefits for defined scenarios, and develop test scenarios, including expected results and lists to be used for each scenario. Create, upload, and analyze various files to perform automated test exercises on the PBM platform, and reconcile and evaluate completed test files, providing progress reports to the management.
- Implement initiatives to optimize resources and reduce errors during the testing period and for special initiatives. Report to management any situation that could put the defined plan in jeopardy.
- Identify and report any findings or coding errors to the Specialist and the PBM team, ensuring a prompt response to the reported issues. Actively participate in discussions and follow up with the PBM regarding these findings and coding errors, and collaborate with the Specialists to implement corrections.
- Collaborates with management in preparing an internal testing plan for the modifications of the current pre-authorizations that cross the calendar year, updated by the PBM for the drugs that suffered changes.
- Conducts test claims on the updates of MediSpan for pharmacy and medical components, and test claims on the updates of formularies and benefits for all company business lines. Also, conducts claim tests of the changes requested to the PBM or changes requested by the regulations or memos to comply with regulatory agencies.




- Participates in meetings with the different PBMs related to formulary and benefits discussions, and implementation and specifications of each group for the creation of the Benefit Specification Forms (BSF).
- Validates the Benefit Specification Forms and Benefit Change Forms to ensure the benefits of each group are properly coded.
- Validate that the formularies and benefits, along with all special drug lists, are coded correctly and on time in the PBM platforms so that they adjudicate correctly from their effective date.
- Actively participates in the preparation and analysis of audits conducted by various regulatory agencies, as well as internal monitoring processes.
- Provide detailed information on the results of formulary and benefit tests, including any incidents or errors, enabling directors to develop the necessary corrective action plans required by Compliance. Additionally, prepare comprehensive reports for the management to facilitate informed decision-making regarding coding errors in drug listings, as well as formulary decisions and changes to benefits.
- Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
- May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor's Degree in Natural Sciences, Pharmacy or related fields is preferred. At least five (5) years of experience in coding benefits, forms, and/or medical claims in a PBM or in the Healthcare Insurance industry.

“Proven experience may be replaced by previously established requirements.”

Certifications / Licenses: Not required.

Other: Advanced knowledge of Excel is required.

Languages

Spanish – Advanced (comprehensive, writing and verbal)

English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”

📌 Pharmacy Test Implementation Lead (San Juan)
🏢 MCS Healthcare Holdings, LLC (MCS)
📍 San Juan