Senior Pharmacy Benefits Manager

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

📋 Description

• Take responsibility for pharmacy trends within the commercial business sector.

• Manage the relationship with the Pharmacy Benefit Manager (PBM) and the associated contract.

• Break down pharmacy trends into unit costs, utilization, traditional and specialty drivers.

• Collaborate with Finance to create and balance a savings-initiative pipeline.

• Lead the procurement process for PBM and Request for Proposals (RFPs); negotiate and re-negotiate contract terms.

• Monitor guarantees, handle independent claims and rebate/pass-through audits, perform market checks, and recover variances.

• Assess new PBM and contracting models and provide recommendations on whether to build or switch.

• Create and track pharmacy trend Key Performance Indicators (KPIs).

• Analyze claims data and Business Intelligence (BI) tools to detect spikes, identify high-cost claimants, and pinpoint leakage.

• Oversee PBM implementations, formulary modifications, plan design rollouts, and audits.

• Maintain plans for implementation, including milestones, dependencies, owners, deadlines, and status updates.

• Coordinate with PBMs, vendors, and communications to ensure operational readiness for launches.

• Evaluate results post-launch, focusing on savings and necessary corrective actions.

• Supervise formulary and utilization management strategies, encompassing prior authorization, step therapy, and quantity limits.

• Manage strategies for specialty and high-cost claimants, including site-of-care, channel decisions, carve-in/carve-out strategies, stop-loss, and risk-sharing considerations.

• Promote the strategy for preferred products and their adoption.

• Collaborate with Finance, Legal, Compliance, Clinical, Data, medical plan vendors, and client HR/Total Rewards teams.

• Convert pharmacy economics into actionable recommendations for senior leadership, fiduciary committees, and clients.

• Oversee the pharmacy member experience, handling appeals, escalations, coverage communications, and open enrollment materials.

• Establish and manage ERISA fiduciary oversight processes, which include committee support, benchmarking, RFPs, audits, and documentation.

• Report directly to the AVP of Pharmacy.

⛳️ Requirements

• 5-8+ years of experience in pharmacy benefits, PBM operations/account management, payer/managed care pharmacy, or benefits consulting, with a proven track record of managing PBM contracts and drug trend outcomes.

• Extensive and up-to-date knowledge of PBM economics, including pricing/discount guarantees, rebates, spread, formulary and utilization management levers, and specialty drug oversight.

• Demonstrated success in trend management.

• Proficiency in claims data analysis, financial modeling, and BI tools.

• Strong project and program management skills for complex, multi-stakeholder initiatives.

• Familiarity with ERISA fiduciary responsibilities and CAA/RxDC transparency requirements.

• Capacity to deliver precise, specific, and candid status reports.

• Exceptional communication abilities.

• PharmD or RPh is highly preferred.

• A Master's degree (MBA, MPH, MS) or background in actuarial/financial fields is desirable.

• Experience in a benefits consultancy pharmacy practice or within the PBM/payer sector, including client-facing account management.

• Experience with self-insured/plan-sponsor environments.

• Familiarity with using Large Language Models (LLMs) to create prompts and lightweight tools is an advantage.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.

• Generous paid time off policies.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all roles, except those at the Director level and above.

• Parental leave program.

• 401K retirement plan.