PBM Operations Lead

EmpiRx Health, LLC• US,

4d•Remote

About The Position

EmpiRx Health is the leading clinically-driven pharmacy benefits management company. As the pioneer in value-based pharmacy care, EmpiRx Health puts its customers and members first by enabling them to take control of their pharmacy benefits, healthcare outcomes, and financial results. We place more emphasis on member care than any other PBM by focusing on health outcomes first. Our pharmacists and clinicians are at the center of everything we do―and our population health solution delivers tailored strategies for our clients. Leveraging our newly launched, AI-powered pharmacy care platform, Clinically™, EmpiRx Health’s pharmacists and client experience teams provide the highest quality pharmacy care to our clients and their members. This enables benefits plan sponsors to keep their members healthy, happy, and productive, while substantially reducing prescription drug spending, which has been on an explosive growth trajectory in recent years. EmpiRx Health is in unprecedented growth, and we're seeking a highly skilled and experienced PBM Operations Team Lead. In this critical role, The PBM Operations Team Lead plays a critical role in managing the operational performance, quality, and continuous improvement of EmpiRx Health’s pharmacy benefit processes. This position leads a multi-disciplinary team of analysts responsible for eligibility, accumulators, and claims adjudication accuracy for a designated client book of business. The Lead ensures high-quality data integrity, timely resolution of client issues, and operational excellence across PBM systems. Serving as a subject matter expert and strategic operational leader, the role drives collaboration with internal partners such as IT, Data Engineering, Client Management, Production Support, and external TPAs to resolve complex issues, enhance service delivery, optimize scalable processes, define future solutions, and support sustained organizational growth.

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 & 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

Nice To Haves

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

Responsibilities

Lead a multi-disciplinary team of analysts responsible for ensuring timely issue resolution, data accuracy, and operational efficiency across eligibility, accumulator, and claims adjudication functions.
Serve as the subject matter expert regarding PBM platforms, eligibility, accumulator management, and claims adjudication processes in accordance with plan design.
Monitor daily performance metrics and implement process improvements that enhance operational efficiency and scalability.
Ensure all operational activities align with contractual requirements, service level expectations, and internal quality standards.
Support speed, agility, and proficiency in 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 (UAT) for new client implementations, plan amendment changes, TPA changes, and system enhancements.
Drive or support the configuration and implementation of engineering solutions required to onboard new clients, support TPA changes, and manage open enrollment during peak periods.
Provide coaching, guidance, and direct oversight to a multi-disciplinary team of analysts, driving performance excellence and accountability.
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 identify, communicate, and resolve complex issues.
Bridge the gap between business and technology stakeholders internally and externally by ensuring clear, efficient communication and generating insights that bring awareness to 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 ensure data security standards are applied across data and analytic pipelines, operational systems, and workflows.
Participate in internal audits and ensure findings are remediated promptly.
Investigate current systems to identify areas for enhancement, quality improvement, and risk reduction.
Build and maintain strong working relationships with TPAs, ensuring seamless onboarding, configuration updates, and resolution of client-specific issues.
Collaborate with external vendors and internal stakeholders to enhance capabilities and reporting accuracy.