Senior Pharmacy Performance & Operations Specialist

🔥 15 hours ago

🏈 Alabama, Arizona, +30 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote ⚓ Rhode Island – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote

💵 $81.7k - $103.3k / year

⏰ Full Time

🟠 Senior

⚙️ Operations

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GEHA Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1937

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

GEHA Health is a large benefits association dedicated to serving federal employees, retirees, and their families. Founded by postal workers in 1937, GEHA offers a comprehensive range of health and dental plans, including FEHB and PSHB options, as well as additional benefits such as gym memberships, vision benefits, and wellness rewards. With a network of 1. 7 million providers nationwide and extensive prescription drug coverage, GEHA prioritizes reinvesting profits to enhance member experiences and support federal workforce health. Their plans include Medicare Advantage options and a robust telehealth offering, ensuring their members receive the best possible care and coverage.

📋 Description

• Oversee PBM contract performance and alignment with contractual guarantees and federal program requirements • Prepare, validate, and submit annual pharmacy benefit changes for FEHB and PSHB programs • Develop division reports, dashboards, and executive-level presentation materials • Manage PBM contractual credits, including reporting, validation, and quality assurance • Monitor and enforce PBM contractual and regulatory compliance • Serve as subject matter expert for pharmacy benefits, commercial benefit design, and configuration • Draft, review, and coordinate PBM performance-related penalty letters and enforcement actions • Support contract governance, performance reviews, issue escalation, and resolution tracking • Monitor call center performance metrics and drive solutions to improve member experience • Track eligibility changes and population shifts and assess impacts on pharmacy benefit performance • Identify contractual or operational gaps and develop corrective action plans • Review pharmacy-related Customer Success content for accuracy and benefits alignment • Respond to internal and external audit inquiries and maintain audit readiness • Validate production and pre-production claims accuracy against benefit design and contract terms • Investigate and resolve complex pharmacy-related member issues and escalations • Manage day-to-day pharmacy program operations and implement new initiatives • Serve as primary PBM liaison for operational issues, program implementation, and eligibility matters • Coordinate cross-functional efforts to resolve PBM-related issues and improve performance

🎯 Requirements

• Bachelor's degree in healthcare administration, Pharmacy, Business Administration, Public Health, or related field • Minimum of 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 requirements and regulatory expectations, including FEHB/PSHB program knowledge • Proficiency in Microsoft Office Suite • Ability to build dashboards, analyze trends, and interpret performance data • Skilled in understanding and applying contractual terms to operational scenarios • Ability to diagnose issues, identify root causes, and develop solutions • Ability to explain complex pharmacy concepts and decisions • Strong accuracy in reviewing claims, reports, and compliance documentation • Ability to work with internal teams, PBM partners, and regulatory stakeholders • Ability to translate complex PBM, financial, and regulatory concepts into clear, actionable insights • Ability to provide non-cellular high-speed internet service such as fiber, DSL, or cable modem for a home office • Minimum internet speed of 30 Mbps download and 5 Mbps upload • Latency response time lower than 80 ms • Hotspots, satellite, and wireless internet service are not allowed • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Competitive pay/salary ranges • Incentive plan • Health/Vision/Dental benefits effective day one • 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution • Robust employee well-being program • Paid Time Off • Personal Community Enrichment Time • Company-provided Basic Life and AD&D • Company-provided Short-Term & Long-Term Disability • Tuition Assistance Program • Remote and work-from-home flexibility