Solutions Architect (Healthcare Payer and PBM Operations)

Job-ID29079678Reference26-23114Remote100% Remote Remote Job Contract to Hire Important Notes from HM: 1. Proficiency in innovating ideas and solutions resulting in tangible and measurable business outcomes. 2. Mastery in creating architecture solutions within the enterprise architecture future state for technological acceleration of value outcomes, and effectively present and persuade key decision makers to invest in this acceleration. 3 Healthcare Payer and PBM Operations: Deep knowledge of and experience with health insurance and Pharmacy Benefit Management (PBM) business models, processes, capabilities, and supporting information systems, including pharmacy benefit design, formulary management, drug pricing, pharmacy networks, eligibility, claims, rebates, utilization management, specialty pharmacy, and member/provider services. 4. Pharmacy Benefit Administration: Strong understanding of the end-to-end pharmacy benefit lifecycle, including benefit configuration, formulary and drug list management, prior authorization, step therapy, quantity limits, accumulator management, specialty drugs, pharmacy network administration, claims adjudication, reversals, coordination of benefits, and payment/reconciliation. 5. Healthcare Payer Architecture: Comprehensive knowledge of, and experience with, payer business capabilities and the relationships among Membership/Enrollment, Benefits, Provider Management, Claims, Care Management, Utilization Management, Pharmacy, Billing, Finance, Customer Service, and Digital/Mobile capabilities. 6. PBM Ecosystem: Understanding of the integration points among health plans, PBMs, pharmacies, pharmacy networks, pharmaceutical manufacturers, wholesalers, clearinghouses, providers, members, and government/regulatory organizations. 7. Healthcare Interoperability Standards and Regulations: Working knowledge of HIPAA, CMS requirements, NCPDP standards, HIPAA EDI transactions (e.g., HL7, FHIR, X12), Medicare Part D, Medicaid pharmacy requirements, and applicable federal and state pharmacy regulations. 6. Healthcare Integration: Strong understanding of API, event-driven, batch, EDI, and real-time integration patterns used to exchange eligibility, benefit, provider, pharmacy, drug, claims, authorization, and financial information. Other Skills: Ability to define canonical data models, information flows, integration contracts, APIs, events, and data governance requirements. Ability to evaluate commercial products and platforms and make buy/build/reuse/replace recommendations. Ability to motivate and influence others so that architecture objectives are met in a timely and consistent manner Ability to collaborate with stakeholders to develop high quality, architecture solutions and technical designs based on approved standards. Ability to coach peers and team members across multiple business and technology disciplines. Ability to provide solution architectural consulting to business leaders, program leaders, product owners, and delivery teams Ability to set architectural solutions across multiple initiatives or domains aligned to platform/product roadmaps and facilitate implementation of approved solution. Effective organizational/interpersonal/relationship management, analytical/systems thinking, communications (written and verbal) and collaboration across multiple business and IT teams. PURPOSE: Responsible for establishing strategic technology direction and creating solution architecture for large complex initiatives/projects. Responsible for the strategic design of technical solutions for complex business problems that are in line with established and emerging technology standards, patterns, and best practices. Primary accountability for architecture work takes place during the lifecycle of major transformation/modernization Initiatives/projects, from planning through implementation. Provides technical oversight and strategic direction to IT project teams in order to deliver key solutions to business problems. Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education Level: Bachelor's Degree Education Details: Computer Science, IT related field Experience: 10 years experience as an infrastructure architect In Lieu of Education In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. Preferred Qualifications Master’s degree in Computer Science or related field preferred. Experience in the development, implementation, and maintenance of large-scale systems, preferably across multiple hardware and software platforms (in the health care industry). Experience with intranet development and implementation is a plus. Knowledge, Skills and Abilities (KSAs) Strong development and integration technology experience, Expert Excellent communication skills both written and verbal., Expert Ability to lead, coordinate, and manage complex projects., Expert Solution architecture and integration architecture design experience, Expert Deep understanding of emerging technologies, including cloud, big data, BPM, AI/ML, or robotics etc, Expert EEO: “Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”