Senior Pharmacy Performance & Operations Specialist

This is a fully remote position, open to applicants in Alabama, +31 more states.

📋 Description

• Oversee the performance of PBM contracts, ensuring alignment with contractual commitments and federal program regulations.

• Prepare, validate, and submit annual changes to pharmacy benefits for the FEHB and PSHB programs.

• Develop reports, dashboards, and presentation materials for executive-level audiences.

• Manage contractual credits from PBM, which includes reporting, validation, and quality assurance.

• Monitor and enforce compliance with PBM contracts and regulatory standards.

• Act as the subject matter expert on pharmacy benefits, commercial benefit design, and configuration.

• Draft, review, and coordinate penalty letters and enforcement actions related to PBM performance.

• Support contract governance, conduct performance reviews, escalate issues, and track resolutions.

• Monitor performance metrics of the call center and implement solutions to enhance member experience.

• Track changes in eligibility and population dynamics, assessing their impact on pharmacy benefit performance.

• Identify operational or contractual gaps and formulate corrective action plans.

• Review pharmacy-related Customer Success content to ensure accuracy and alignment with benefits.

• Address inquiries from internal and external audits and maintain readiness for audits.

• Validate claims accuracy in both production and pre-production against benefit design and contract stipulations.

• Investigate and resolve complex member issues and escalations related to pharmacy services.

• Oversee daily operations of the pharmacy program and implement new initiatives.

• Serve as the primary liaison for PBM regarding operational issues, program implementation, and eligibility concerns.

• Coordinate cross-functional efforts to resolve PBM-related challenges and enhance performance.

⛳️ Requirements

• Bachelor's degree in healthcare administration, Pharmacy, Business Administration, Public Health, or a related field.

• At least 5 years of progressive experience in pharmacy operations, pharmacy benefit management (PBM), health plan operations, or federal health program administration.

• Familiarity with federal pharmacy benefit regulations and requirements, including knowledge of FEHB/PSHB programs.

• Proficiency in the Microsoft Office Suite.

• Ability to create dashboards, analyze trends, and interpret performance data.

• Skilled in applying contractual terms to operational contexts.

• Ability to diagnose problems, identify root causes, and devise solutions.

• Capable of explaining complex pharmacy concepts and decisions clearly.

• Strong attention to detail when reviewing claims, reports, and compliance documents.

• Capacity to collaborate with internal teams, PBM partners, and regulatory stakeholders.

• Ability to translate complex PBM, financial, and regulatory concepts into clear, actionable insights.

• Must provide high-speed internet service to a home office, such as fiber, DSL, or cable modem.

• Minimum internet speed of 30 Mbps for downloads and 5 Mbps for uploads.

• Latency response time must be less than 80 ms.

• Use of hotspots, satellite, and wireless internet services is prohibited.

• A dedicated workspace is required to minimize interruptions and protect member PHI/HIPAA information.

🏝️ Benefits

• Competitive salary and pay ranges.

• Incentive plan.

• Health, Vision, and Dental benefits effective from day one.

• 401(k) retirement plan with company match – dollar for dollar up to 4% of employee contributions (includes pretax or Roth options) plus a 6% annual company contribution.

• Comprehensive employee well-being program.

• Paid Time Off.

• Personal Community Enrichment Time.

• Company-provided Basic Life and Accidental Death & Dismemberment (AD&D) insurance.

• Company-provided Short-Term and Long-Term Disability coverage.

• Tuition Assistance Program.

• Flexibility for remote work and work-from-home options.