PBM Operations Lead

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

📋 Description

• Oversee a diverse team of analysts tasked with ensuring accuracy in eligibility, accumulators, and claims adjudication.

• Act as the subject matter expert regarding PBM platforms, eligibility, accumulator management, and claims adjudication processes.

• Track daily performance metrics and implement improvements that boost operational efficiency and scalability.

• Ensure that operational activities are in line with contractual obligations, service level expectations, and internal quality standards.

• Assist in resolving issues, mitigating risks, and making operational decisions.

• Conduct root-cause analysis and develop corrective action plans for recurring operational challenges.

• Lead or support configuration requirements and user acceptance testing for new client implementations, plan amendments, TPA changes, and system enhancements.

• Drive or assist in engineering solutions for new client onboarding, TPA changes, and open enrollment periods.

• Provide coaching, guidance, and direct supervision to analysts.

• Foster a collaborative, high-performing team culture centered around problem-solving and continuous improvement.

• Collaborate with Client Management, Data Engineering, IT, and other cross-functional teams to address complex issues.

• Serve as a liaison between business and technology stakeholders by communicating risks, trends, and opportunities.

• Identify operational risks and formulate mitigation strategies.

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

• Maintain data integrity and security across pipelines, systems, and workflows.

• Participate in internal audits and ensure timely remediation of findings.

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

• Establish and nurture relationships with TPAs for onboarding, configuration updates, and client-specific issue resolution.

• Collaborate with external vendors and internal stakeholders to improve capabilities and ensure reporting accuracy.

⛳️ Requirements

• Bachelor’s degree in business administration, Healthcare Administration, Pharmacy Administration, Information Systems, Computer Science, Data Analytics, or a related field.

• Alternatively, five years of relevant experience in the healthcare industry with increased responsibilities may be accepted in lieu of a degree.

• A minimum of two years of experience in healthcare eligibility, accumulators, claims, or a related field.

• At least one year of experience in a leadership, supervisory, or team lead role.

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

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

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

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

• Comprehensive knowledge of HIPAA, PHI, PII, and healthcare compliance regulations.

• Familiarity with pharmacy benefit configurations and adjudication workflows.

• Certifications in Agile, data analytics, or project management.

• Healthcare-related certifications.

• Over 2 years of experience with Azure Databricks.

• Experience in processing automation and initiatives aimed at operational scalability.

• Experience leading large-scale client implementations, open enrollment support, or platform migrations.

🏝️ Benefits

• Paid Time Off

• 401(k) program

• Health Insurance, including Dental & Vision coverage

• Student Loan Reimbursement

• Health Savings Account

• Employee Assistance Program