Pharmacy Benefits Service Manager

Your role in our mission

Provide overall leadership for PBM operations supporting large State Medicaid management client programs.  

 PBM Operations includes the business, clinical, and technical solutions which support the scope of the client pharmacy services contract.  

 Directly responsible for building high-level relationships with the client, and the strategic partners who support the contract scope of services.

Serve as primary point of contact and provide leadership accountability for PBM strategy and service operations for the client.

Provide direction and mentoring to front line management team responsible for day-to-day operations, ensuring contract objectives and service levels are met consistently.  

Work with teams to routinely perform resource capacity planning and team member skills assessment to identify and drive staffing and training.  

These managers have operational responsibility for claims, prior authorization, call center, and rebate administration.  

Other managers reporting to the PBSM will support trend analytics, formulary management and quality improvement.

Provide senior leader oversight of business/clinical processes, staffing and technical solutions to maximize overall quality and efficiency, and within approved budgets.  

Work with client leadership to understand drivers of utilization and quality, identify new clinical and operational program opportunities to drive overall program effectiveness.  

Partner with internal stakeholders to develop solutions and pricing to achieve profitability objectives on new client programs, or changes to existing programs.

Provide leadership oversight of team(s) responsible for new client initiatives and projects.  Lead solutioning efforts with teams.  

Ensures project milestones and deliverables are met, and routine client communication occurs.  

Identify and drive continuous process improvement initiatives to improve the value and cost effectiveness of pharmacy service operations, including recommending changes to mix of offerings, and the systems and operations through which it is delivered.

Provide leadership to the Business Office Manager who is responsible for the cost accounting requirements for business operations, and for management oversight of the tracking of hours as outlined in the contract.  

Work with Business Office Manager to provide routine reporting and communication with the client regarding these hours.  

Lead routine team meetings with the client where overall program status is reviewed, including a review of service level metrics, status of program change requests and projects, and issue management.
 
Provide internal leadership and innovation in driving new technical solutions in line with the PBM business.  Work directly with internal business partners and technical staff assigned to the account.

Gather feedback from client on program results; analyze feedback and incorporate same into future programs. Identify and determine global implications of program parameters and work with senior leadership to redefine or revise as appropriate.

What we're looking for

1.    A minimum of three years operational responsibility for pharmacy claims, prior authorization, call center, and rebate administration.  

2.    Success in a client service role, balancing client relations and satisfaction with account profitability objectives, including negotiating contract changes for variations in scope of service and volumes of work

3.    Demonstrated success in driving process documentation, measurement and process improvement initiatives to enhance the efficiency and effectiveness of PBM operations.

4.    Comfort in managing staff and budgets

5.    The ability to operate effectively under a shared service model where certain functions are centralized, such as finance and IT support.

What you should expect in this role

This is an account leadership and client relations role, and the Manager is expected to be available onsite in Austin to establish an account team culture, maintain a clear sense of client strategy and priorities, and develop opportunities to expand Gainwell services in pharmacy and assist in growth strategies in other Medicaid service offerings.
 

Work Closely with...

•    VP/GM – Pharmacy

•    Implementation Leadership 

•    Engineering / IT – Director of Engineering, Pharmacy Services 

•    Business Process Services – shared services function providing claims, call center and clinical support

o    Operations Manager

o    Clinical Manager

o    Business Manager

o    Rebate Manager

What Success Looks Like

•    One year – Texas pharmacy operations are six months past a go-live with minimal member or provider friction and are operating in steady state.

 Account is responding to monthly changes to FDB and new drugs.  

Drivers of trend are well understood, and the account is engaged with the client and vendor partners in driving quarterly changes to the PDL / formulary to improve program performance.  

The client is satisfied with the efforts of the account and its RDUR vendor is identifying and driving initiatives to improve clinical quality and reduce fraud, waste and abuse.

 

•    Three years – The account is at maturity, with a client pleased to give references for other Medicaid RFPs.  

The account is meeting profit targets and service level agreements.  

In addition to their Texas-focused deliverables, account leaders also serve as SMEs who assist in the development of strategy and implementation of other pharmacy accounts.  

Opportunities for program improvement have resulted in at least one change order through which Gainwell has improved account profitability.