Senior Manager – Drug Trend Management Pipeline Development

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

📋 Description

• Assess drug cost, safety, and integrity opportunities within Part B and Part D.

• Rigorously evaluate signals, populations, expenditures, existing controls, and ongoing initiatives.

• Compile clinical justifications based on labeling, compendia, guidelines, comparative efficacy, safety, and member impact considerations.

• Define and quantify the financial opportunity.

• Formulate hypotheses regarding the issue and identify the relevant lever or owner.

• Present evidence-driven cases to utilization management, payment integrity, SIU, policy, PBM, network, and other relevant stakeholders.

• Identify dual- or multiple-natured opportunities and clarify the needs of each function.

• Provide feedback on false positives, near-misses, and unsuccessful patterns to enhance detection processes.

• Monitor the reasons for abandoning opportunities to avoid redundant efforts.

• Gradually assume greater responsibility for generating and prioritizing opportunities as detection capabilities enhance.

• Report directly to the Director of Clinical Pharmacy.

⛳️ Requirements

• Extensive expertise and immersion in the pharmacy sector, with a demonstrated capacity to leverage this knowledge for drug cost, safety, and integrity opportunities.

• A minimum of 5-8 years of experience in managed care pharmacy, utilization management, drug trend analysis, or program integrity, with significant exposure to Part B and Part D.

• Strong analytical instincts at the population level; adept at reasoning about cohorts and trends across a wide range of members.

• In-depth understanding of Medicare regulations, including protected classes, negative formulary change rules, CMS submission timelines, transition fills, the coverage boundary between Part B and Part D, and appeals implications.

• Practical experience with pharmacy claims data (NCPDP, GPI, DAW, NDC) and medical claims data (HCPCS, buy-and-bill, units billed versus administered).

• Excellent written and verbal communication abilities.

• Comprehensive knowledge spanning payment integrity, data science, actuarial functions, and investigative processes.

• Evidence of continuous learning, such as developing a query library, automating manual tasks, or mastering an unassigned tool.

• Proven experience in enhancing processes from within the workplace.

• Familiarity with building or collaborating with detection, suspicion, or FWA models.

• Practical perspective on agentic or LLM-assisted tools.

• Understanding of payment integrity, SIU, or actuarial workflows.

• Thoroughness with data, including open versus closed periods, shifting denominators, and range-based analysis.

• Comprehension of matrix organizational frameworks within a health plan, MA-PD plan sponsor, or PBM environment.

• Profound domain knowledge in drug trend management and pharmacy operations.

• Clinical credentials, such as a PharmD, are preferred but not mandatory.

🏝️ Benefits

• Employer-sponsored health, dental, and vision insurance with minimal or no premium.

• Generous paid time off policy.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all roles, excluding Director and above.

• Parental leave program.

• 401K program.