PBM Operations Lead

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee a diverse team of analysts tasked with managing eligibility, accumulators, and claims adjudication operations.

• Supervise operational performance, quality assurance, and the ongoing enhancement of pharmacy benefit procedures.

• Act as the expert on PBM systems, eligibility criteria, accumulator management, and claims adjudication practices.

• Track daily performance indicators and apply scalable improvements to processes.

• Ensure that operational functions meet contractual obligations, service level agreements, and internal quality benchmarks.

• Facilitate the resolution of issues, risk mitigation, operational decision-making, root-cause analysis, and planning for corrective actions.

• Lead or assist in the configuration requirements and user acceptance testing for client implementations, plan modifications, TPA adjustments, and system upgrades.

• Lead or assist in configuring engineering solutions and implementation for new client onboarding, TPA modifications, and open enrollment periods.

• Mentor, guide, and directly supervise analysts while fostering accountability and continuous improvement.

• Collaborate with Client Management, Data Engineering, IT, Production Support, and external TPAs to address complex issues and enhance service delivery.

• Relay risks, trends, and opportunities to both business and technology stakeholders.

• Recognize operational risks and create strategies for mitigation.

• Ensure compliance with HIPAA, GDPR, PHI, and PII data security protocols.

• Safeguard data integrity and security throughout data and analytic pipelines, operational systems, and workflows.

• Engage in internal audits and ensure timely resolution of any identified issues.

• Explore systems for enhancements, quality improvements, and risk reduction.

• Establish and nurture relationships with TPAs for onboarding, configuration modifications, and resolution of client-specific concerns.

• Partner with vendors and internal teams to enhance capabilities and improve reporting accuracy.

⛳️ Requirements

• Bachelor’s degree in business administration, Healthcare Administration, Pharmacy Administration, Information Systems, Computer Science, Data Analytics, or a similar field, or five years of progressively responsible experience in the healthcare sector in lieu of a degree.

• At least two years of experience in healthcare eligibility, accumulators, claims, or a related area.

• A minimum of one year in a leadership, supervisory, or team lead role.

• Strong understanding of eligibility and accumulator management, benefit configuration, and claims adjudication processes.

• Experience in managing operational escalations and cross-functional projects.

• Excellent analytical, problem-solving, communication, and stakeholder management abilities.

• Capability to establish and maintain strong working relationships with external partners (TPAs), including support for onboarding, configuration updates, and resolution of client-specific issues.

• Solid knowledge of HIPAA, PHI, PII, and healthcare compliance standards.

• Familiarity with pharmacy benefit configurations and adjudication workflows.

• Possession of Agile, data analytics, or project management certifications.

• Relevant healthcare certifications.

• Over two years of experience with Azure Databricks.

• Experience in processing automation and initiatives for operational scalability.

• Background in leading large-scale client implementations, supporting open enrollment, or managing platform migrations.

🏝️ Benefits

• Paid Time Off

• 401(k) program

• Health Insurance, including Dental & Vision coverage

• Student Loan Reimbursement

• Health Savings Account

• Employee Assistance Program