Summary
The Director of Pharmacy Operations & PBM Management will guide and improve our Federal Employee Health Benefit (FEHB) and Postal Services Health Benefits (PSHB) environment as market, member, and regulatory needs change.
We are looking for a strategic Health Plan Pharmacy leader to manage delegated PBM contract oversight (inclusive of utilization and formulary management), oversee clinical initiatives and programs (Medication Therapy Management, HEDIS/Quality) and monitor disputed claims processes. This leader will also partner closely with the VP of Pharmacy and other enterprise leadership to drive business outcomes and meet regulatory, affordability, clinical quality, and corporate goals.
In this role, your leadership will:
Evolve our pharmacy management model by partnering with stakeholders and vendors to better outline the total cost of care capabilities.
Collaborate with internal and external partners to achieve business goals aligned with short-term and long-term strategies.
Empower others to support G.E.H.A in improving member experience and growth.
Duties
Pharmacy Strategy & Operations Oversight
- Set strategic direction for program development, achieving appropriate outcomes and business performance measures related to access, affordability, quality, and experience, including business performance, clinical pharmacy operations, PBM and vendor oversight, utilization management, and formulary.
- Ensure operational excellence of the pharmacy benefit program at G.E.H.A.
- Partner with internal stakeholders regarding clinical programming, product development, benefit design, and vendor negotiations.
- Manage department staff (clinical and non-clinical) performance, development, and succession planning. Foster departmental development and ensure high performance to support the organization’s mission and strategic goals.
- Lead cross-functional initiatives with internal and external partners to improve pharmacy program efficiency and innovation.
PBM Contract Oversight & Performance Management
- Day to day management of the commercial PBM and Medicare Part D / EGWP administrator relationships for the FEHB and PSHB lines of business.
- Analyze and track PBM performance against key performance indicators, ensuring alignment with corporate goals.
- Oversee changes in pharmacy benefits implemented by the PBM, ensuring compliance and strategic alignment.
- Regulatory Compliance & Accreditation
- The role ensures compliance with all relevant contracts, accreditation criteria, and federal regulations, including those from OPM for Federal Employee Health Benefits (FEHB) and Postal Services Health Benefits (PSHB) along with those for CMS for Medicare Part D / Employer Group Waiver Plan (EGWP) through our administrator.
- Monitor and interpret the CMS and OPM landscape, implement OPM Carrier Letters, develop policies and procedures to maintain compliance, and partner with the GEHA Compliance teams to provide documentation and notification of compliance initiatives.
Financial & Clinical Program Leadership
- Lead the development and execution of financial strategies for drug pricing, discounts, rebates, and reimbursement to optimize plan cost savings.
- Oversee department budgetary aspects of the pharmacy department, ensuring fiscal accountability and cost-effectiveness.
- Collaborate with teams across the clinical division to implement clinical programs that enhance quality, patient safety, and medication adherence.
Requirements
- Licensed pharmacist (PharmD) required.
- 10+ years of experience in managed care pharmacy, pharmacy benefit management, or the PBM industry.
- 5-7+ years of experience managing PBM relationships and contracts.
- 5+ years in leadership roles with a focus on operational and strategic oversight.
- Expertise in formulary management, utilization management, and regulatory compliance in both commercial and government programs.
Preferred Qualifications
- An advanced degree (e.g., Master’s in Healthcare Administration or Business Administration) is preferred.
- Knowledge of FEHB federal benefits and Medicare Part D / EGWP regulations.
- Strong problem-solving and decision-making skills.
- Proficiency in data analysis, financial modeling, and performance metrics.
- Ability to manage multiple initiatives and meet deadlines in a demanding environment.
- Excellent verbal, written, and collaboration skills.
- Experience with accreditation standards and regulatory compliance frameworks.
- Demonstrated ability to lead cross-functional teams and drive organizational change.
GEHA is an Equal Employment Opportunity and/or Affirmative Action 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. We are committed to creating an inclusive environment for all employees.
