Sr. Pharmacy Performance & Operations Specialist

GEHA; Missouri; Hybrid; USD 82,000 - 115,000; Full time

Benefits offered by this job

Health/Vision/Dental benefits

401(k) retirement plan with company-mt

Paid Time Off

Tuition Assistance Program

Hybrid/work-from-home options

Job summary

Government Employees Health Association, Inc. (G.E.H.A) seeks a Sr. Pharmacy Performance & Operations Specialist to oversee FEHB and PSHB pharmacy programs, drive PBM performance, and ensure contractual and regulatory compliance.

The role acts as SME and liaison to the PBM, delivering data-driven insights for strategic decisions. The ideal candidate has 5+ years in PBM/pharmacy operations, strong analytical skills, and experience building dashboards.

Qualifications

• Bachelor's degree in healthcare administration, Pharmacy, Business Administration, Public Health, or related field.
• A minimum of 5 years of progressive experience in pharmacy operations, PBM, health plan operations, or federal health program administration (FEHB/PSHB).
• FEHB/PSHB program knowledge: familiarity with federal requirements and regulatory expectations.
• Analytical and reporting skills: proficiency in building dashboards and interpreting performance data.
• Contract interpretation: understanding contractual terms and applying them to operations.
• Problem-solving abilities: diagnosing issues and developing solutions.
• Communication skills: explaining complex PBM concepts clearly.
• Attention to detail: accuracy in reviewing claims, reports, and compliance docs.
• Cross-functional collaboration: working with internal teams, PBM partners, and regulators.
• Executive communication: translating PBM/financial/regulatory concepts into insights.

Responsibilities

• Oversee PBM contract performance and ensure alignment with guarantees and federal requirements.
• Prepare, validate, and submit annual pharmacy benefit changes for FEHB/PSHB.
• Develop division reports, dashboards, and executive presentations to monitor plan performance.
• Manage PBM contractual credits, including reporting, validation, and QA processes.
• Monitor and enforce PBM contractual obligations and regulatory requirements.
• Serve as SME for pharmacy benefits including design and configuration.
• Draft and coordinate PBM performance-related letters and actions.
• Support contract governance activities and issue escalation.
• Monitor call center performance, identify trends, drive solutions for member experience.
• Track eligibility changes and population shifts impact on performance.
• Identify gaps and develop corrective action plans.
• Review pharmacy-related Customer Success content for accuracy.
• Respond to audit inquiries with documentation and readiness.
• Validate production and pre-production claims accuracy with benefit design terms.
• Investigate and resolve complex pharmacy-related member issues and escalations.
• Manage day-to-day program operations and new initiatives.
• Serve as liaison to PBM for operations, implementation, and eligibility matters.
• Coordinate cross-functional efforts to resolve PBM issues and drive performance.

Skills

Analytical skills

Reporting skills

Contract interpretation

Problem solving

Communication skills

Attention to detail

Cross functional collaboration

Executive communication

Stakeholder management

Education

Bachelor's degree in healthcare administration/Pharmacy/Business Admin/Public Health

Advanced degree (MPH/MHA/MBA/PharmD)

Tools

Tableau

Power BI

Microsoft Office

Job description

Company Overview

Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care. G.E.H.A has one mission: To empower federal workers to be healthy and well.

Position Overview

The Sr. Pharmacy Performance & Operations Specialist is responsible for oversight, performance management, and operational execution of G.E.H.A’s FEHB and PSHB pharmacy programs. This role owns PBM performance monitoring, contractual compliance, and operational integrity, ensuring alignment with regulatory requirements and enterprise objectives. The position serves as a subject matter expert and primary liaison to the PBM, driving issue resolution, enforcing contractual obligations, and delivering data-driven insights to inform strategic decisions and optimize member outcomes.

Duties and Responsibilities

• Oversee PBM contract performance, ensuring alignment with contractual guarantees and federal program requirements.
• Prepare, validate, and submit annual pharmacy benefit changes for FEHB and PSHB programs.
• Develop division reports, dashboards, and executive-level presentation materials to monitor plan performance.
• Manage PBM contractual credits, including reporting, validation, and quality assurance processes.
• Monitor and enforce compliance with PBM contractual obligations and applicable regulatory requirements.
• Serve as a subject matter expert for pharmacy benefits, including commercial benefit design and configuration.
• Draft, review, and coordinate PBM performance-related penalty letters and enforcement actions.
• Support contract governance activities, including performance reviews, issue escalation, and resolution tracking.
• Monitor call center performance metrics, identify trends, and drive solutions to improve member experience.
• Track eligibility changes and population shifts, assessing impact on pharmacy benefit performance and operations.
• Identify contractual or operational gaps and develop corrective action plans to address shortfalls.
• Review pharmacy-related Customer Success content to ensure accuracy, consistency, and alignment with benefits.
• Respond to internal and external audit inquiries, providing documentation and ensuring audit readiness.
• Validate production and pre-production claims accuracy, ensuring alignment with benefit design and contract terms.
• Investigate and resolve complex pharmacy-related member issues and escalations.
• Manage day-to-day pharmacy program operations, including implementation and administration of new initiatives.
• Serve as the primary liaison to the PBM for operational issues, program implementation, and eligibility matters.
• Coordinate cross-functional efforts with internal stakeholders to resolve PBM-related issues and drive performance improvement.
• Perform other duties as assigned to support pharmacy program performance and operational objectives.

Knowledge, Skills, and Abilities

Education: Bachelor's degree in healthcare administration, Pharmacy, Business Administration, Public Health, or related field.

A minimum of 5 years of progressive experience in pharmacy operations, pharmacy benefit management (PBM), health plan operations, or federal health program administration (e.g., FEHB, PSHB).

FEHB/PSHB program knowledge: Familiarity with federal pharmacy benefit requirements and regulatory expectations.

Analytical and reporting skills: Proficiency in Microsoft Office Suite and ability to build dashboards, analyze trends, and interpret performance data.

Contract interpretation: Skilled in understanding and applying contractual terms to operational scenarios.

Problem-solving abilities: Capable of diagnosing issues, identifying root causes, and developing solutions.

Communication skills: Able to explain complex pharmacy concepts and decisions.

Attention to detail: Strong accuracy in reviewing claims, reports, and compliance documentation.

Cross functional collaboration: Ability to work with internal teams, PBM partners, and regulatory stakeholders.

Executive communication: ability to translate complex PBM, financial, and regulatory concepts into clear, actionable insights.

Preferred Qualifications

Advanced pharmacy, healthcare, or business administration degree (e.g., MPH, MHA, MBA, PharmD).

Data visualization tools: Experience with Tableau, Power BI, or similar platforms.

Project management certification: PMP, CAPM, or equivalent.

Regulatory compliance experience: Familiarity with OPM, CMS, or other federal oversight bodies.

Process improvement training: Lean, Six Sigma, or similar methodologies.

Work-at-Home Requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
• Latency (ping) response time lower than 80 ms
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Compensation and Benefits

• Competitive pay/salary ranges
• Incentive plan
• Health/Vision/Dental benefits effective day one
• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
• Robust employee well-being program
• Paid Time Off
• Personal Community Enrichment Time
• Company-provided Basic Life and AD&D
• Company-provided Short-Term & Long-Term Disability
• Tuition Assistance Program

Location and Eligibility

While this is a remote opportunity, at this time G.E.H.A does not hire employees from U.S. territories or the following states: Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine.

G.E.H.A is headquartered in Lee's Summit, Missouri, in the Kansas City area.

We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.

Salary Information

Please note that the salary information is a general guideline only. G.E.H.A considers factors such as (but not limited to) scope and responsibilities of the position, candidate’s work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer. The target hiring range for this position is $81,672 - $103,320 USD. At G.E.H.A, the current maximum salary for this role is $115,128 USD. While initial compensation may vary based on experience and qualifications, there is a path to work toward this top rate through performance and continued growth within the organization.

Equal Opportunity Employer

G.E.H.A is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. G.E.H.A will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. We are committed to creating an inclusive environment for all employees.

Company Culture and Benefits Highlight

Your FUTURE is here with us –COME GROW WITH G.E.H.A! Benefits start on day one! Great 401(k) match! Tuition assistance programs! Professional development! Advancement opportunities! For additional information, please visit GEHA Careers.