PBM Operations Lead - Drive Efficiency & Outcomes

Empirx-Health-4; United States; On-site; USD 110,000 - 190,000; Full time

Benefits offered by this job

Paid Time Off

401(k) program

Health Insurance (Dental & Vision)

Student Loan Reimbursement

Health Savings Account

Employee Assistance Program

Job summary

EmpiRx Health seeks a seasoned PBM Operations Team Lead to guide a multidisciplinary group handling eligibility, accumulators and claims adjudication for a designated client base. You will drive data integrity, operational excellence and timely issue resolution across PBM processes.

Key responsibilities include leading teams, optimizing configurations, and partnering with IT, Data Engineering and Client Management to deliver scalable solutions and ensure compliance with HIPAA and related

Qualifications

• Bachelor’s degree or 5 years of healthcare industry experience with increasing responsibility
• Minimum of two years of experience in healthcare eligibility, accumulators, and claims
• Minimum of one year of leadership or team lead experience
• Strong knowledge of eligibility, accumulator management, benefit configuration, and claims adjudication

Responsibilities

• Lead a multi-disciplinary team of analysts ensuring timely issue resolution, data accuracy and efficiency across eligibility, accumulator and claims adjudication functions
• Serve as subject matter expert regarding PBM platforms, eligibility, accumulator management and claims adjudication processes per plan design
• Monitor daily performance metrics and drive process improvements for efficiency and scalability
• Ensure activities align with contracts, SLAs and internal quality standards
• Support rapid issue resolution, risk mitigation and operational decision-making
• Drive root-cause analysis and corrective action planning for recurring issues
• Support configuration requirements and UAT for new client implementations and plan changes
• Oversee onboarding of new clients, TPA changes and open enrollment during peak periods
• Provide coaching and leadership to analysts and promote high-performance culture
• Partner with cross-functional teams to resolve complex issues and communicate risks and opportunities
• Identify operational risks and develop mitigation strategies

Skills

Leadership

Stakeholder management

Data analysis

Project management

Communication

Agile

Problem-solving

Education

Bachelor’s degree in business administration, Healthcare Administration, Pharmacy Administration, Information Systems, Computer Science, or Data Analytics

Tools

Azure Databricks

Job description

EmpiRx Health seeks a seasoned PBM Operations Team Lead to guide a multidisciplinary group handling eligibility, accumulators and claims adjudication for a designated client base. You will drive data integrity, operational excellence and timely issue resolution across PBM processes.

Key responsibilities include leading teams, optimizing configurations, and partnering with IT, Data Engineering and Client Management to deliver scalable solutions and ensure compliance with HIPAA and related