Operations Lead - Government Pharmacy Benefit Management
Offer summary
Qualifications:
Bachelor's degree in Business Administration, Healthcare Administration, or related field; Master's preferred., 10+ years of progressive PBM operations experience, including 5+ years in leadership roles., 8+ years of experience managing government healthcare program operations such as Medicare, Medicaid, or ACA., Deep understanding of PBM transaction processing systems, claims adjudication, and regulatory requirements..Key responsibilities:
- Design and implement PBM operational infrastructure for government healthcare programs.
- Oversee prescription claims processing and formulary management for Medicare, Medicaid, and ACA plans.
- Lead cross-functional teams to ensure compliance, operational efficiency, and integration of clinical and regulatory requirements.
- Develop and monitor KPIs, quality assurance programs, and continuous improvement initiatives.
Job description
RxSense is a leading healthcare technology company delivering innovative solutions for pharmacy benefits and prescription savings. Our enterprise platform brings transparency, flexibility, and efficiency to pharmacy benefit management, helping clients streamline operations and enabling consumers to save on prescriptions. By integrating intelligence across the pharmacy ecosystem, RxSense makes cost-effective healthcare more accessible. Whether for PBMs, pharmacies, or individuals, our solutions help modernize operations, reduce costs, and improve outcomes.
RxSense also owns and operates SingleCare, a free prescription savings service that offers consumers access to consistently low prices on prescription drugs. Through its partnerships with the country’s largest pharmacies and grocers, including CVS, Walgreens, Walmart, Kroger and Albertsons, SingleCare improves access and adherence to affordable medications and has helped millions of Americans save over $11 billion on their medications.
RxSense is a great place to work! Our company has earned several prestigious awards, including Fast Company’s Most Innovative Companies, Forbes’ Top Startup Employers, Modern Healthcare's Best Places to Work in Healthcare, and Inc’s Best in Business and Best Workplaces.
Position Overview:
The Operations Lead will serve as the core leader for building and managing our PBM operational infrastructure and workflows, with a specific focus on government healthcare programs including Medicare Part D, Medicaid, and ACA marketplace plans. This role is essential for establishing scalable, efficient operational foundations while ensuring seamless integration of compliance and clinical requirements across all service delivery channels.
Key Responsibilities:
Operational Infrastructure Development
- Design and implement comprehensive PBM operational infrastructure and workflows for government healthcare programs
- Establish service delivery standards that meet or exceed CMS, state Medicaid, and ACA regulatory requirements
- Develop operational policies, procedures, and performance metrics aligned with federal and state program requirements
- Create staffing models and organizational structures to support efficient service delivery across all channels
- Lead benefit, formulary, and network implementations
Transaction Processing & Claims Management
- Oversee prescription drug claims processing systems for Medicare Part D, Medicaid, and ACA plans
- Implement and manage formulary administration, including tier structures and utilization management programs
- Develop mail-order pharmacy operations and specialty pharmacy services
Cross-Functional Leadership
- Serve as cross-functional leader to prioritize development needs across departments
- Collaborate with compliance teams to ensure operational frameworks incorporate all regulatory requirements
- Partner with clinical teams to integrate medication therapy management (MTM) services
- Align technology requirements with operational needs for claims adjudication and data integration
- Work with finance teams to implement accurate pricing methodologies (e.g., NADAC, MAC pricing)
Government Program Operations
- Develop Medicare Part D operational processes including:
- Coverage determination and appeals (CDAG/ODAG) workflows
- Transition fills and continuity of care protocols
- Low-Income Subsidy (LIS) beneficiary management
- Part D reporting and compliance monitoring
- PDE submission and oversight
- Establish Medicaid program operations including:
- State-specific formulary management
- Prior authorization workflows
- Preferred Drug List (PDL) administration
- Encounter submission oversight
- Implement ACA marketplace PBM operations
Performance Management
- Develop and monitor key performance indicators (KPIs) for all operational functions
- Establish quality assurance programs for claims processing accuracy
- Implement continuous improvement initiatives to enhance efficiency and reduce costs
- Create operational dashboards for real-time monitoring of service levels
- Manage vendor relationships
Required Qualifications
- Bachelor's degree in Business Administration, Healthcare Administration, or related field; Master's preferred
- 10+ years of progressive PBM operations experience, with 5+ years in leadership roles
- 8 + years of experience managing government healthcare program operations (Medicare, Medicaid, or ACA)
- Proven track record of building operational infrastructure from the ground up
Technical Expertise
- Deep understanding of PBM transaction processing systems and claims adjudication
- Experience with benefit, formulary, and pharmacy network administration
- Knowledge of drug pricing methodologies (AWP, WAC, NADAC, MAC)
- Familiarity with PBM technology platforms and data integration systems
- Understanding of formulary management and utilization management programs
Regulatory Knowledge
- Comprehensive knowledge of Medicare Part D regulations and CMS requirements
- Understanding of state Medicaid pharmacy benefit requirements
- Familiarity with ACA marketplace regulations affecting PBMs and the ACA pharmacy benefit
- Experience with government program audits and compliance reviews
Leadership Skills
- Proven ability to lead cross-functional teams and complex projects
- Strong change management and organizational development skills
- Excellent communication and stakeholder management abilities
- Strategic thinking with operational execution capabilities
- Experience building and mentoring high-performing teams
Preferred Qualifications
- MBA or MHA degree
- PMP or Six Sigma certification
- Experience with start-up or rapid growth PBM organizations
- In-depth knowledge of health plan and PBM pharmacy operations
Key Competencies
- Strategic planning and execution
- Process improvement and optimization
- Data-driven decision making
- Regulatory compliance mindset
- Customer service orientation
- Innovation and adaptability
- Financial acumen
- Relationship building
RxSense believes that a diverse workforce is a more talented and productive workforce. As such, we are an Equal Opportunity and Affirmative Action employer. Our recruitment process is free from discriminatory hiring practices and all qualified applicants are considered for employment without regard to race, color, religion, sex, gender, sexual orientation, gender identity, ancestry, age, or national origin. Neither will qualified applicants be discriminated against on the basis of disability or protected veteran status. We believe in the strength of the collaboration, creativity and sense of community a diverse workforce brings.
Required profile
Experience
Other Skills
- Communication
- Leadership
- Strategic Thinking
- Relationship Building
Related jobs
Western Funding, Inc.
- From: Texas (USA) (Full Remote)
- Full time
HMG Careers
- From: Canada (Full Remote)
- Full time
SAGAN
- From: Wyoming (USA) (Full Remote)
- Freelance
xAI
- From: United States (Full Remote)
- Full time
Databricks
- From: Italy (Full Remote)
- Full time