Senior Pharmacy Operations Specialist

massgeneralbrigham; Somerville (MA); On-site; USD 90,000 - 120,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a Senior Pharmacy Operations Specialist to lead the administration, implementation, monitoring and continuous improvement of the pharmacy benefit for Commercial and Medicaid members within the Mass General Brigham system.

This senior role combines operational expertise with data analytics, vendor oversight, regulatory support, and cross-functional project leadership to deliver compliant, high-quality pharmacy benefits.

Qualifications

• Bachelor's degree in a related field or equivalent experience.
• 5-7 years of pharmacy benefit or related healthcare experience.
• 3-5 years with pharmacy claims, benefit configuration, formulary or PBM operations.
• Experience with data analytics tools, SQL, and reporting.
• Ability to lead cross-functional initiatives.

Responsibilities

• Ensure effective day-to-day administration of the pharmacy benefit across all lines of business.
• Research and resolve complex operational issues, identify root causes, and implement sustainable corrective solutions.
• Monitor pharmacy operational processes and identify and advance opportunities to improve efficiency, accuracy, and quality.
• Monitor PBM operational performance and hold vendors accountable for timely, accurate deliverables and service standards.
• Coordinate issue resolution, implementations, testing, and ongoing operational activities with the PBM and internal partners.
• Translate benefit and clinical requirements into operational specifications and validate formulary, utilization management, benefit, and claims configurations.
• Support compliance with applicable state, federal, contractual, and regulatory requirements, including audits, regulatory implementations, corrective action plans, and ongoing compliance monitoring for Commercial and Medicaid products.
• Analyze pharmacy claims and operational data to identify trends, anomalies, and opportunities, and develop reporting that supports operational and leadership decision-making.
• Lead cross-functional pharmacy initiatives from requirements through implementation, and serve as a subject matter expert and mentor who promotes consistent processes and operational standards across the Pharmacy Operations team.

Skills

Pharmacy benefit operations

Data analytics

SQL

Project management

Communication

Excel

Regulatory compliance

Education

Bachelor's degree in related field

Tools

Microsoft Office

Job description

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.

We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

The Senior Pharmacy Operations Specialist is a senior-level pharmacy operations professional responsible for ensuring the effective administration, implementation, monitoring, and continuous improvement of the pharmacy benefit for Commercial and Medicaid members. The role combines operational expertise, analytical problem-solving, vendor oversight, system implementation, regulatory support, and project leadership.

Essential Functions

• Ensure effective day-to-day administration of the pharmacy benefit across all lines of business.
• Research and resolve complex operational issues, identify root causes, and implement sustainable corrective solutions.
• Monitor pharmacy operational processes and identify and advance opportunities to improve efficiency, accuracy, and quality.
• Monitor PBM operational performance and hold vendors accountable for timely, accurate deliverables and service standards.
• Coordinate issue resolution, implementations, testing, and ongoing operational activities with the PBM and internal partners.
• Translate benefit and clinical requirements into operational specifications and validate formulary, utilization management, benefit, and claims configurations.
• Support compliance with applicable state, federal, contractual, and regulatory requirements, including audits, regulatory implementations, corrective action plans, and ongoing compliance monitoring for Commercial and Medicaid products.
• Analyze pharmacy claims and operational data to identify trends, anomalies, and opportunities, and develop reporting that supports operational and leadership decision-making.
• Lead cross-functional pharmacy initiatives from requirements through implementation, and serve as a subject matter expert and mentor who promotes consistent processes and operational standards across the Pharmacy Operations team.

Education

• Bachelor's Degree Related Field of Study required; experience can be considered in lieu of a degree

Licenses and Credentials

• Pharmacy Technician license preferred
• Pharmacy Technician Certification license preferred

Experience

• At least 5-7 years of pharmacy benefit, managed care, PBM, health plan, pharmacy operations, or related healthcare experience required
• At least 3-5 years of experience working with pharmacy claims, benefit configuration, formulary, utilization management, or PBM operations required

The ideal candidate will also bring experience in one or more of the following areas:

• Supporting both Commercial and Medicaid pharmacy benefits, ideally for at least 1 year.
• Working directly with a PBM and/or health plan, including pharmacy benefit configuration, claims adjudication systems, and Medicaid/MassHealth pharmacy operations and regulatory requirements.
• Data analytics, reporting tools, or SQL, along with experience leading cross-functional projects and system implementations.

Knowledge, Skills, and Abilities

• Demonstrated ability to analyze complex operational issues and develop effective solutions.
• Strong organizational, project management, communication, and problem-solving skills.
• Proficiency with Microsoft Office, particularly Excel, and the ability to work with operational and claims data.
• Advanced knowledge of pharmacy benefit operations and managed care processes.
• Understanding of formulary management and utilization management programs.
• Strong analytical and investigative skills with the ability to identify root causes.

Additional Job Details (if applicable)

Working Conditions

This is a full-time role with a M