Operations Lead

Summary

Join RxSense, a leading healthcare technology company, as their Operations Lead to build and manage PBM operational infrastructure and workflows, focusing on government healthcare programs like Medicare Part D, Medicaid, and ACA marketplace plans. This crucial role involves designing and implementing comprehensive PBM operational infrastructure, establishing service delivery standards, and developing operational policies and procedures. You will oversee prescription drug claims processing, manage formulary administration, and develop mail-order and specialty pharmacy operations. The position requires cross-functional leadership, collaboration with various teams, and aligning technology with operational needs. You will also develop and monitor key performance indicators (KPIs), implement quality assurance programs, and manage vendor relationships. This role is ideal for a strategic leader with extensive PBM operations experience in government healthcare programs.

Requirements

• 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
• 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
• 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
• 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

Responsibilities

• 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
• 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
• 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)
• 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
• 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

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