Business Change Director - CarelonRx PBM Operations Management

Elevance Health • Tampa, FL

1d • Hybrid

About The Position

The Business Change Director is responsible for working with management to identify and implement varied projects, programs and plans that support achievement of business unit and enterprise goals, with a strong emphasis on Medicare Pharmacy Operations and benefit strategy execution. This role serves as a critical subject matter expert (SME) leading end-to-end benefit configuration, validation, and implementation processes aligned to CMS requirements, ensuring accurate adjudication of pharmacy claims and successful go-live for new plan year initiatives.

Requirements

• Requires a BA/BS in a related field and minimum of 10 years managing mid to large-scale change/project initiatives; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

• Deep expertise in Medicare Part D pharmacy benefits including benefit design, formulary strategy, CMS (Centers for Medicare & Medicaid Services) regulatory requirements, and experience supporting Medicare bid submissions with the ability to translate benefit intent into operational and system requirements strongly preferred.
• Strong knowledge of Pharmacy Benefit Manager (PBM) operations, including vendor partnership (e.g., CVS or similar), claims adjudication processes, and end-to-end benefit configuration lifecycle (documentation, testing, validation, and production deployment) strongly preferred.
• Demonstrated experience supporting CMS audits (program, financial, or data validation), ensuring compliance, and managing highly regulated, deadline-driven environments such as annual plan year (1/1) go-live and command center activities strongly preferred.
• Proven ability to interpret complex health plan benefit requirements, translate into accurate adjudication logic, and manage high-priority production issues with speed, precision, and accountability in time-sensitive environments strongly preferred.
• Strong cross-functional leadership experience partnering with product, clinical, compliance, and external vendor teams, with the ability to influence outcomes without direct authority and operate effectively in a highly matrixed organization strongly preferred.
• Exceptional strategic thinking, attention to detail, and communication skills, including experience engaging senior leadership, combined with healthcare payer experience (Medicare pharmacy operations highly preferred), advanced degree, and/or Six Sigma Black Belt certification preferred.

Responsibilities

• Serves as the primary Medicare pharmacy benefit SME, partnering with health plan product, clinical, and PBM/vendor teams (e.g., CVS) to interpret benefit intent and translate into accurate system configuration and execution.
• Leads end-to-end benefit build lifecycle including documentation, CMS submission support, configuration logic, testing, validation, and promotion to production for Medicare pharmacy benefits.
• Identifies potential issues, impacts to adjudication logic, and scope changes, and drives rapid resolution for critical, time-sensitive production or pre-production issues.
• Leads efforts to identify and implement best practices related to Medicare pharmacy benefit design, PBM operations, and claims adjudication processes.
• Identifies impacted parties, business partners, and resources required across cross-functional teams including product, clinical, compliance, and vendor partners.
• Develops and designs processes and systems that ensure accurate benefit setup, regulatory compliance, and operational readiness for annual bid and go-live cycles.
• Designs methods for integrating benefit configuration processes across systems, vendors, and internal teams to ensure seamless execution.
• Provides process, project, and change management methodology coaching/consulting support with a focus on highly complex, regulatory-driven initiatives.
• Leads prioritization and execution of benefit-related initiatives tied to CMS deadlines and annual Medicare bid cycles.
• Provides expertise in culture/change management activities within a fast-paced, high-accountability environment with critical deadlines (e.g., 1/1 go-live).
• Supports execution of the operating plan with accountability for accuracy of benefit logic, successful implementation, and operational readiness.

Benefits

• a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 5,001-10,000 employees