Benefit Configuration Specialist

Position SummaryThe Benefit Configuration Specialist is responsible for supporting the testing and validation of pharmacy benefit plan configurations across multiple lines of business, including Commercial, Medicaid, Exchange, and Medicare. This role ensures that benefit plan setups align with client intent, regulatory requirements, and internal configuration standards. The Specialist will execute comprehensive benefit testing, participate in pre-implementation audits, and validate plan accuracy prior to deployment. Responsibilities include reviewing plan design specifications, performing scenario-based testing, identifying configuration discrepancies, and collaborating with cross-functional teams to resolve issues. This position requires strong attention to detail, analytical thinking, and the ability to interpret complex pharmacy benefit structures. The ideal candidate is comfortable working in a fast-paced environment, managing multiple audits simultaneously, and communicating findings clearly to internal stakeholders.Position ResponsibilitiesExecute end-to-end testing and validation of pharmacy benefit plan configurations across Commercial, Medicaid, Exchange, and Medicare lines of business.Perform detailed implementation audits to ensure benefit setup aligns with client intent, regulatory requirements, and internal configuration standards.Review and interpret plan design documents, benefit change forms, and formulary specifications to translate requirements into executable test scenarios.Analyze claim outputs to confirm expected adjudication behavior and accumulator movement.Identify, document, and communicate configuration discrepancies or defects; collaborate with configuration team to ensure timely resolution.Ensure compliance with applicable federal and state regulations, including guidance from the Centers for Medicare & Medicaid Services (CMS) where applicable.Maintain clear documentation of testing results, audit findings, and approval signoffs.Participate in client-facing meetings to review testing scope, discuss audit findings, clarify benefit intent, and provide detailed explanations of testing results and configuration outcomes.Partner with cross-functional teams to ensure benefit accuracy and successful implementation.Contribute to process improvements that enhance testing efficiency, audit quality, and overall benefit validation standards.Manage multiple audits and testing initiatives simultaneously in a deadline-driven environment.Adhere to the Capital Rx Code of Conduct.Required QualificationsBachelor's degree in Healthcare Administration, Business, Information Systems, or related field (or equivalent experience).Minimum 3–5 years of experience in pharmacy benefit management (PBM), health plan operations, or benefit configuration.Direct experience supporting Medicare lines of business (Medicare Part D and/or MAPD).Demonstrated understanding of Medicare benefit structures.Experience testing and validating pharmacy benefit configurations in Commercial, Medicaid, Exchange, and/or Medicare lines of business.Strong knowledge of formulary design, tier structures, utilization management (PA, ST, QL), and accumulator logic.Ability to analyze benefit design documents and translate requirements into executable test scenarios.Strong analytical skills with high attention to detail and accuracy.Proficiency in Microsoft Excel for data review, validation, and reporting.Strong written and verbal communication skills with ability to clearly document findings and discrepancies.Participate in client-facing discussions to review benefit testing outcomes and implementation readiness while providing clear guidance on complex benefit designs.Base SalaryBase salary range: $75,000 – $90,000 USD, varying by location and market tier. Hybrid positions are available in New York, NY and Denver, CO; remote candidates receive a salary within the same range determined by geographic location.BenefitsMedical, pharmacy, dental, vision, accidental injury, critical illness, hospital indemnity, and flexible spending accounts.Health savings account for full-time employees.Voluntary life insurance and voluntary accidental death and dismemberment insurance for employees and eligible dependents.Basic life insurance and basic accidental death and dismemberment insurance at no cost to the employee.Paid time off, sick time, holidays, short-term disability, long-term disability, employee assistance program, and wellness program.401(k) plan with company match after one year of full-time employment.Equal Employment Opportunity StatementCapital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.J-18808-Ljbffr