Pharmacy Benefits Senior Manager

Job description

Job Description A bit about this role: 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. Responsibilities and Impact will include: PBM Relationship & Vendor Management. 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. Specifically, you will: 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 Pharmacy Trend Management & Analytics. 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. You will: 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 Implementation & Project Management. 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. You will: 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 Clinical & Formulary Strategy. Perform oversight of formulary and utilization management strategy for lowest net cost, not highest rebate, including prior authorization, step therapy, and quantity limits. You will: 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 Cross-Functional Coordination. 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. You will: 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 Compliance & Fiduciary Oversight. 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. Required skills and experience: 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. Desired skills and experience: 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. Salary Range: $110,500–$173,000 a year #LI-REMOTE The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: 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. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.