Pharmacy Operations Manager

Job title: Pharmacy Operations Manager

Location: Remote, must sit in CST or EST 

Job Summary:

The Pharmacy Operations Manager plays a pivotal role in providing operational and clinical support for pharmacy benefits across sales, account management, and plan sponsor functions. This position is responsible for managing end-to-end Pharmacy Benefit Manager (PBM) implementations, ensuring timely and accurate claim adjudication, and serving as the primary liaison between the Health Plan and PBM partners. The role supports enterprise-wide pharmacy installations, Medicare compliance efforts (including PDE submissions), and acts as a subject matter expert on benefit setup, reporting, and pharmacy-related inquiries.

Key Responsibilities:

• Educate internal stakeholders (sales, account management) on pharmacy benefit structures, policies, and value propositions.
• Lead the setup of pharmacy benefits for new accounts, including RFP support and implementation with PBM partners.
• Act as a day-to-day liaison for pharmacy operations, addressing inquiries from plan sponsors, members, and internal departments.
• Use PBM reporting platforms to generate and deliver ad-hoc and standard pharmacy reports to support strategic account decisions.
• Oversee enterprise-wide pharmacy implementations, including installation, claim adjudication testing, and accumulator validations.
• Troubleshoot claim adjudication and benefit configuration issues in collaboration with PBM partners and internal systems teams.
• Lead PBM implementation meetings and ensure all data exchanges and operational inputs are aligned with system and regulatory requirements.
• Monitor inbound and outbound eligibility and accumulator feeds, addressing any fallouts or inconsistencies promptly.
• Maintain operational SLAs and quality benchmarks for pharmacy support teams, ensuring a high standard of service delivery.
• Provide expert support on Medicare-related inquiries, including plan copays, deductibles, and sales questions.
• Lead Medicare Part D operations support, including PDE file preparation and submission.
• Collaborate with marketing and compliance teams to ensure readiness and accuracy of materials for the 2026 Medicare plan year.

Key Skills & Competencies:

• In-depth knowledge of PBM operations, claim adjudication systems, and pharmacy benefit configuration.
• Familiarity with Medicare Part D, PDE processes, and CMS compliance standards.
• Strong cross-functional collaboration skills, especially with IT, compliance, sales, and PBM vendors.
• Experience in project management and benefit implementation oversight.
• Proficient in pharmacy-related reporting tools and platforms.
• Effective communicator and team leader capable of translating complex pharmacy benefit language to non-clinical audiences.
• High attention to detail and ability to maintain SLA and quality standards in a dynamic environment.

Qualifications:

• Bachelor’s degree in Pharmacy, Business Administration, Healthcare Management, or a related field required.
• Minimum of 5 years of experience in pharmacy benefits management, health plan operations, or a related field.
• Experience working with PBM vendors and implementing pharmacy benefits.
• Strong analytical skills with experience in data-driven decision-making.
• Knowledge of federal and state regulatory requirements related to pharmacy operations.
• Proficiency in Microsoft Office Suite and PBM-related software platforms.

Pay: The pay for this role is $63-$68 an hour DOE. 

Benefits through CGC:  Dental, Vision, STD and/or LTD, Voluntary Life & AD&D, Accident, Critical Illness, Hospital Indemnity, Health Advocate EAP, and Health Equity Commuter Benefits, ZayZoon, and 401k.

 We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws