Note: The job is a remote job and is open to candidates in USA. EmpiRx Health is a clinically driven pharmacy benefits management company focused on improving health outcomes and reducing prescription drug spending. The PBM Operations Team Lead manages operational performance, quality, and continuous improvement across eligibility, accumulators, and claims adjudication processes while leading a multidisciplinary analyst team. The role also drives cross-functional issue resolution, compliance, vendor relationships, system enhancements, and scalable operational solutions.
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
Skills
- 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
- 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
Benefits
- Subject to program eligibility, this position qualifies for Paid Time Off.
- Subject to program eligibility, this position qualifies for a 401(k) program.
- Subject to program eligibility, this position qualifies for Health Insurance including Dental & Vision coverage.
- Subject to program eligibility, this position qualifies for Student Loan Reimbursement.
- Subject to program eligibility, this position qualifies for a Health Savings Account.
- Subject to program eligibility, this position qualifies for an Employee Assistance Program.
- Remote work
Company Overview