QA Manager – Pharmacy Benefit Management (PBM)

Job Title: QA Manager – PBM
Experience: 10+ years in Quality Assurance, with strong experience in Pharmacy Benefit Management (PBM)
Employment Type: Contract / C2C
Location: Remote

Job Overview
We are seeking an experienced QA Manager with strong Pharmacy Benefit Management (PBM) domain expertise to lead quality assurance activities, test strategy, and delivery for pharmacy benefits platforms and applications. The ideal candidate will have hands-on experience in PBM business processes, prescription claims adjudication, pharmacy networks, formulary management, eligibility, and NCPDP transaction standards.

The QA Manager will oversee manual and automation testing teams, ensure end-to-end testing coverage, manage test execution and defect resolution, and collaborate with business stakeholders, developers, business analysts, and product teams to deliver high-quality PBM solutions.

Key Responsibilities
· Lead and manage QA teams responsible for testing PBM applications, systems, and integrations.

· Develop and implement comprehensive test strategies, test plans, test scenarios, and test execution schedules.

· Manage end-to-end testing for PBM business processes, including:

o Prescription drug claims processing and adjudication.

o Member eligibility and enrollment.

o Pharmacy network management and reimbursement.

o Formulary, drug pricing, and benefit configuration.

o Prior authorization and utilization management.

o Rebate processing, accumulator management, and member cost-sharing.

o Coordination of Benefits (COB) and claims reversals and resubmissions.

· Ensure testing coverage for NCPDP D.0 transactions, including B1 (billing), B2 (reversal), and B3 (rebilling).

· Oversee integration testing between PBM platforms, pharmacies, health plans, third-party vendors, and downstream financial systems.

· Manage SIT, UAT, regression, functional, integration, and end-to-end testing activities.

· Define QA metrics, KPIs, defect trends, test coverage, productivity, and quality reporting for stakeholders.

· Coordinate defect triage meetings, root cause analysis, and resolution with development and business teams.

· Establish QA standards, testing best practices, documentation guidelines, and process improvements.

· Manage test data preparation, test environments, release validation, and production readiness activities.

· Identify project risks, testing dependencies, and quality issues, and develop mitigation plans.

· Drive test automation initiatives where applicable and evaluate opportunities to improve testing efficiency.

· Ensure compliance with applicable healthcare, pharmacy, privacy, and data security requirements.

· Provide regular status reports to project leadership and ensure timely delivery of quality releases.

Required Qualifications
· 10+ years of experience in software quality assurance, including leadership or QA management responsibilities.

· Strong experience in the Pharmacy Benefit Management (PBM) domain.

· In-depth understanding of pharmacy claims adjudication and prescription drug processing workflows.

· Strong knowledge of NCPDP standards and pharmacy claim transaction processing.

· Experience managing QA teams across multiple testing phases and releases.

· Hands-on experience with test planning, test case design, test execution, defect management, and test reporting.

· Experience with SQL queries for database validation, backend testing, and claims data verification.

· Experience with test management and defect tracking tools such as Jira, HP ALM/Quality Center, or similar tools.

· Knowledge of Agile/Scrum methodologies and SDLC/STLC processes.

· Strong communication, analytical, leadership, stakeholder management, and problem-solving skills.

Preferred Qualifications
· Experience with PBM platforms such as MedImpact, Express Scripts, Caremark, Optum Rx, or other pharmacy claims processing systems.

· Knowledge of NCPDP transaction standards, pharmacy eligibility, formulary, pricing, and reimbursement.

· Experience with EDI, APIs, web services, and third-party system integrations.

· Familiarity with automated testing tools such as Selenium, Playwright, or API testing tools such as Postman.

· Experience in healthcare payer, Medicare Part D, Medicaid pharmacy benefits, or commercial prescription benefit programs.

· Knowledge of HIPAA requirements and healthcare data privacy practices.

· Experience with test automation strategy, continuous integration, and continuous delivery.

Key Skills
· Pharmacy Benefit Management (PBM)

· QA Management and Team Leadership

· Pharmacy Claims Adjudication

· NCPDP D.0 – B1, B2, B3

· Functional, Integration, SIT, UAT, and Regression Testing

· Eligibility and Enrollment

· Formulary and Benefit Configuration

· Pharmacy Network and Reimbursement

· SQL and Database Validation

· Defect Management and Root Cause Analysis

· Test Strategy, Planning, and Execution

· Jira / HP ALM

· Agile / Scrum

· Healthcare Compliance and HIPAA