PBM Operations Lead

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟠 Senior

⚙️ Operations

👻 Ghost score 12%

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EmpiRx Health

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2014

🏥 Healthcare

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

Healthcare • Healthcare Insurance • Artificial Intelligence

EmpiRx Health is a clinically-driven pharmacy benefits management (PBM) company that uses a Medication Optimization (MO) operating model to improve patient outcomes and lower drug costs. The company combines in-house clinical pharmacists, peer-to-peer physician collaboration, and AI-powered population health and analytics technology (the Clinically™ platform and Population Health Engine) to assess pharmacy claims, identify clinically appropriate medication interventions, guarantee auditable savings to plan sponsors, and provide high-touch member care advocacy. EmpiRx partners with plan sponsors and health plans to replace traditional rebate-driven PBM models with value- and outcomes-based pharmacy care.

📋 Description

• Lead a multi-disciplinary team of analysts responsible for eligibility, accumulators, and claims adjudication functions • Manage operational performance, quality, and continuous improvement of pharmacy benefit processes • Serve as the subject matter expert for PBM platforms, eligibility, accumulator management, and claims adjudication processes • Monitor daily performance metrics and implement scalable process improvements • Ensure operational activities align with contractual requirements, service level expectations, and internal quality standards • Drive issue resolution, mitigation, operational decision-making, root-cause analysis, and corrective action planning • Drive or support configuration requirements and user acceptance testing for client implementations, plan amendments, TPA changes, and system enhancements • Drive or support engineering solution configuration and implementation for new client onboarding, TPA changes, and open enrollment • Coach, guide, and directly oversee analysts while promoting accountability and continuous improvement • Partner with Client Management, Data Engineering, IT, Production Support, and external TPAs to resolve complex issues and improve service delivery • Communicate risks, trends, and opportunities across business and technology stakeholders • Identify operational risks and develop mitigation strategies • Ensure adherence to HIPAA, GDPR, PHI, and PII data security standards • Maintain data integrity and security across data and analytic pipelines, operational systems, and workflows • Participate in internal audits and ensure prompt remediation of findings • Investigate systems for enhancement, quality improvement, and risk reduction • Build and maintain relationships with TPAs for onboarding, configuration updates, and client-specific issue resolution • Collaborate with vendors and internal stakeholders to improve capabilities and reporting accuracy

🎯 Requirements

• Bachelor’s degree in business administration, Healthcare Administration, Pharmacy Administration, Information Systems, Computer Science, Data Analytics, or a related field, or five years of experience in the healthcare industry with increasing responsibility in lieu of a degree • Minimum of two years of experience working with healthcare eligibility, accumulators, and claims, or a related field • Minimum of one year of leadership, supervisory, or team lead experience • Strong knowledge of eligibility and accumulator management, benefit configuration, and claims adjudication • Experience managing operational escalations and cross-functional initiatives • Strong analytical, problem-solving, communication, and stakeholder management skills • Ability to build and maintain strong working relationships with external partners (TPAs), including support for onboarding, configuration updates, and resolution of client-specific issues • Strong working knowledge of HIPAA, PHI, PII, and healthcare compliance requirements • Familiarity with pharmacy benefit configurations and adjudication workflows • Agile, data analytics, or project management certifications • Healthcare certifications • 2+ years of experience with Azure Databricks • Experience in processing automation and operational scalability initiatives • 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