PBM Operations Lead

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟠 Senior

⚙️ Operations

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

EmpiRx Health

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2014

🏥 Healthcare

💊 Pharmaceuticals

⚕️ Healthcare Insurance

Healthcare • Pharmaceuticals • Healthcare Insurance

EmpiRx Health is a clinically-driven, pharmacist-led pharmacy benefits management (PBM) company that focuses on medication optimization and value-based pharmacy care. The company centers pharmacists in its operating model, leveraging AI-powered analytics and population health tools to make evidence-based medication recommendations, improve patient outcomes, and reduce total drug spending for plan sponsors. EmpiRx offers a technology-enabled PBM platform and services to employers, health plans, and pharmacies, emphasizing customer-first service, guaranteed clinical savings, and preservation of community pharmacies.

📋 Description

• Lead a multi-disciplinary team of analysts responsible for eligibility, accumulators, and claims adjudication accuracy • Serve as the subject matter expert on PBM platforms, eligibility, accumulator management, and claims adjudication processes • Monitor daily performance metrics and implement process improvements that enhance operational efficiency and scalability • Ensure operational activities align with contractual requirements, service level expectations, and internal quality standards • Support issue resolution, mitigation, and operational decision-making • Drive root-cause analysis and corrective action planning for recurring operational issues • Drive or support configuration requirements and user acceptance testing for new client implementations, plan amendments, TPA changes, and system enhancements • Drive or support engineering solutions for new client onboarding, TPA changes, and open enrollment periods • Provide coaching, guidance, and direct oversight to analysts • Promote a collaborative, high-performing team culture focused on problem-solving and continuous improvement • Partner with Client Management, Data Engineering, IT, and other cross-functional teams to resolve complex issues • Bridge business and technology stakeholders by communicating risks, trends, and opportunities • Identify operational risks and develop mitigation strategies • Ensure adherence to HIPAA, GDPR, PHI, and PII data security standards • Maintain data integrity and data security across pipelines, systems, and workflows • Participate in internal audits and ensure findings are remediated promptly • 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 external vendors and internal stakeholders to enhance 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 • In lieu of a degree, five years of experience in the healthcare industry with increasing responsibility may be considered • 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