Manager, Benefit Design & Requirements

Responsibilities

• PBM Benefit Consulting:
• Serve as the primary PBM subject matter expert and trusted advisor to new and existing clients throughout the implementation lifecycle and steady state benefit changes, guiding them from initial benefit design through validated go-live
• Lead structured discovery sessions with clients and consultants cross-functionally to document plan-level intent, formulary structures, cost-sharing logic, accumulator rules, specialty tier design, step therapy protocols, and coverage gap parameters
• Proactively identify gaps in client-provided documentation; work directly with the implementation lead or client manager to resolve issues before build begins, reducing downstream risk
• Advise clients on industry best practices, AffirmedRx platform capabilities, and implementation considerations to help them make informed benefit design decisions
• Benefit Requirements Documentation:
• Translate complex PBM benefit configurations into clear, comprehensive benefit requirement documents that serve as the authoritative source of truth for the build team
• Maintain requirement traceability throughout the lifecycle; ensuring that scope changes are captured, communicated, and reflected in all downstream deliverables
• Build and continuously improve standardized requirement templates, intake frameworks, and documentation standards that scale across client engagements
• Collaborate with Implementation Managers, vendors, TPAs, and clinical operations to ensure full alignment between documented requirements and system configuration
• Benefit Build Review & Configuration Guidance:
• Apply hands-on benefit build knowledge to review configured plans in AffirmedRx adjudication system, validating that the build accurately reflects approved requirements prior to testing
• Act as an internal resource for Implementation team members on PBM benefits, plan design logic, and configuration best practices
• Flag build discrepancies early by leveraging deep familiarity with how benefit rules translate into adjudication logic
• Testing & Go-Live Validation:
• Review and validate end-to-end benefit testing results produced by the adjudication partner, confirming that plan rules, cost-sharing logic, accumulator behavior, and compliance checkpoints align precisely with approved requirements
• Identify gaps in test coverage and request additional scenarios from the adjudication partner to stress-test custom scenarios, benefit interactions, and complex plan configurations
• Lead UAT cycles in coordination with RxSense and internal teams; manage defect logging, resolution tracking, and remediation confirmation
• Deliver clear go-live readiness reports summarizing test outcomes, open items, and risk assessments
• Process Excellence & Team Building:
• Build, standardize, and continuously improve templates for requirements documentation, test plans, test scripts, and defect tracking
• Support audit and compliance activities by ensuring all documentation meets regulatory and contractual standards
• Contribute to post-implementation retrospectives, identifying recurring issues and recommending systemic improvements
• As the function scales, participate in hiring, onboarding, and developing analysts
• What you need:
• 5+ years of experience in pharmacy benefit management (PBM), health plan, or specialty pharmacy operations with direct exposure to benefit configuration or plan design
• Bachelor's degree in Business Administration, Healthcare Administration, Health Informatics, or Pharmacy or related field
• Demonstrated expertise interpreting and translating PBM benefit structures - including formularies, prior authorization, step therapy, accumulators, and cost-sharing designs - into system-ready requirements
• Proven experience designing and executing benefit

Benefits

Additional Information

AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology. Join us in improving health care outcomes for all! We promise to do what's right, always. Position Summary: The Manager, Benefit Design & Requirements (PBM) will be the founding individual contributor of this function, establishing the processes, standards, and institutional knowledge from the ground up. As the function matures, this Manager will have the opportunity to scale the team, hiring and developing analysts beneath them who will carry out the work they defined. In the near term, this person serves as AffirmedRx's resident PBM benefit design expert: guiding new clients through discovery, translating complex plan structures into precise requirement documents, and validating accumulator, rule sets and cost-share tier performs exactly as intended.

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