Pharmacy Benefits Senior Manager

Devoted Health • Waltham, MA

3d • $110,500 - $173,000 • Remote

About The Position

As Pharmacy Benefits Senior Manager, you will own pharmacy trend for our commercial book of business and become the person this organization trusts to tell the truth about where pharmacy dollars actually go. You will own the PBM relationship and the contract underneath it, decompose trend into unit cost and utilization until every driver has a name, build a savings pipeline that gets reconciled against what actually landed, and translate all of it into something a client can act on. You will also run the implementations (formulary changes, PBM transitions, plan-design rollouts) so every team involved, our client included, knows what is happening, what is next, and whether we are on time.
Questions you may find solutions to include:
When our PBM tells us we saved $4M last year, how do we know whether that's real, and how do we show the client the difference between a discount that moved and a cost that actually came down?
Our contract has 27 pricing guarantees. Which three actually determine our cost, are we measuring them the way the PBM measures them, and where is the reconciliation hiding the spread?
A $2.4M gene therapy claim lands in Q1. What should already have been in place at the stop-loss layer, in the clinical policy, and in the client conversation?
What are emerging best-in-class ways to manage trend? Who does it best, and could we do it better?
You will report to the AVP, Pharmacy. Pharmacy is one of the fastest growing costs for plan sponsors. We're hiring the person who is going to change that.

Requirements

• 5-8+ years in pharmacy benefits, PBM operations/account management, payer/managed care pharmacy, or benefits consulting with demonstrable ownership of PBM contracting and drug-trend outcomes.
• Deep, current command of PBM economics: pricing/discount guarantees, rebates, spread, formulary and UM levers, and specialty drug management.
• Proven trend management track record
• Strong analytics foundation: fluent with claims data, financial modeling, and BI tools; able to interrogate the math behind a PBM's reporting
• Rigorous project/program management of complex, multi-stakeholder initiatives.
• Working knowledge of ERISA fiduciary obligations and CAA/RxDC transparency requirements
• You make people confident. Teams and clients trust your status reporting because it is current, specific, and honest about risk. Nobody has to chase you to find out where things stand, and bad news reaches them early enough to act on.
• Outstanding communication. You can distill pharmacy economics into clear, actionable insight for a CFO, a clinician, and a client — sometimes in the same meeting.

Nice To Haves

• PharmD or RPh (strongly preferred; deep clinical fluency is a major plus but not a substitute for PBM/trend and project-management strength)
• Master's degree (MBA, MPH, MS) or actuarial/financial background
• Experience at a benefits consultancy pharmacy practice or on the PBM/payer side, including client-facing account management
• Self-insured/plan-sponsor experience
• AI explorations. A pragmatic approach to emerging tools; experience using LLMs to build prompts and lightweight tooling to speed analysis and reporting is a plus.

Responsibilities

• Serve as the primary owner of the PBM relationship, including day-to-day management, periodic business reviews, and escalations, and be the person who actually knows the contract.
• Lead PBM procurement and RFPs; negotiate and re-negotiate contract terms (pricing/discount guarantees, dispensing fees, rebate guarantees, admin fees, definitions, audit and market-check rights)
• Track every performance and financial guarantee; commission and manage independent claims audits, rebate/pass-through audits, and mid-contract market checks; pursue and recover variances
• Evaluate emerging PBM and contracting models (transparent/pass-through, cost-plus, unbundled/modular) and drive the build-vs-switch analysis and recommendation as the landscape changes
• Own the pharmacy PMPM and total-cost-of-care number. Decompose trend into unit cost vs. utilization and traditional vs. specialty, explain every driver, and forecast next year's PMPM against the drug pipeline, inflation, and new categories.
• Build and run a savings-initiative pipeline as a disciplined project portfolio: scope each initiative, model projected savings, sequence implementation, and reconcile projected vs. realized savings with Finance
• Develop and monitor pharmacy trend KPIs: PMPM/PMPY, generic dispensing rate, specialty vs. traditional split, preferred-product conversion rate, rebate yield, prior-auth/UM savings, and guarantee performance
• Turn claims data into decisions by working fluently across claims data warehouses and BI tools to find spikes, high-cost claimants, and leakage before they surface in a retrospective report
• Run pharmacy as a portfolio of projects with owners, milestones, dependencies, and hard deadlines (PBM implementations, formulary changes, plan-design rollouts, and audits) delivering predictable results through ambiguity in a matrixed environment.
• Build the plan and hold it: scope, sequence, critical path, owners, and dates, with dependencies surfaced early rather than discovered late
• Be the source of truth on status. Neither our internal teams nor our client should ever have to ask whether an implementation is on track. They should already know, because your reporting is current, specific, and candid about risk.
• Coordinate the PBM, vendors, communications, and operational readiness so go-lives happen on the date we committed to and without surprises for members
• Close the loop after go-live: did it work, did it save what we said it would, and what do we fix before the next one
• Perform oversight of formulary and utilization management strategy for lowest net cost, not highest rebate, including prior authorization, step therapy, and quantity limits.
• Own the specialty and high-cost-claimant strategy: site-of-care and channel optimization, specialty carve-in/carve-out decisions, and catastrophic-claimant financial protection (stop-loss coordination, risk-sharing where available)
• Drive preferred-product strategy and adoption using all available marketplace levers
• Be the connective tissue across Finance (budgeting/forecasting/stop-loss), Legal, Compliance, Clinical, Data, the medical plan vendors, and the client's HR/Total Rewards team to integrate pharmacy strategy with medical benefits rather than running it in a silo.
• Translate pharmacy complexity into clear, decision-ready recommendations for senior leadership and the benefits/fiduciary committee, and turn a PMPM waterfall into a narrative a client can act on
• Perform oversight of member experience for pharmacy: appeals, escalations, coverage communications, and open-enrollment materials
• Operate as a prudent ERISA fiduciary and make sure we can prove it. Establish and run the process (committee support, benchmarking, RFPs, audits, documentation) that satisfies the duty of prudence in selecting and monitoring the PBM.

Benefits

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....
• Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed