Director, Health Care Strategy & Plan Economics

Job Description

Job Description

Director Health Care Strategy & Plan Economics

Location: Durham, NC — Hybrid

ABOUT US

Victra is Verizon’s largest premium retailer in the United States. We thrive on collaboration, innovation, and performance. Our mission is to “Connect technology to life in a trustworthy, fun, and profitable way”. We work closely with Verizon and our brand partners to deliver exceptional product offerings, promotions, and campaigns that drive in-store traffic and revenue.

JOB DESCRIPTION

Victra is self-insured for medical benefits, administering claims through a third-party administrator (TPA) and pharmacy benefits through a pharmacy benefit manager (PBM), with stop-loss reinsurance covering catastrophic claims. This role owns the financial performance of that program end to end — the plan's single largest controllable SG&A line outside of labor. The successful candidate will function as an internal actuary, contract negotiator, and plan-design strategist rolled into one, partnering with Finance and HR/Total Rewards to re-underwrite how Victra buys and manages health care. This is a self-funding role expected to identify, execute, and validate savings that are a multiple of its own fully-loaded cost within the first 12–18 months, and to build a durable cost-management discipline thereafter.

Initially an individual contributor, this role may scale to lead 1–2 analysts focused on benefits analytics and vendor management as the program matures.

KEY RESPONSIBILITIES

TPA & Claims Economics

• Own the TPA relationship: performance guarantees, administrative fee benchmarking, claims-payment accuracy audits, and periodic competitive RFPs (typically every 3–5 years) to keep fees and service levels market-tested.
• Commission and act on independent claims audits; recover overpayments and correct systemic adjudication errors.
• Drive dependent eligibility audits, coordination-of-benefits recovery, and subrogation/third-party liability recovery to eliminate ineligible and duplicate spend.

PBM & Pharmacy Spend

• Negotiate and audit PBM contracts for full pricing transparency: pass-through vs. spread pricing, 100% rebate pass-through, guaranteed effective rates, and audit rights — aligned with 2026 PBM reform and DOL fee-disclosure rules that raise ERISA fiduciary expectations for plan sponsors.
• Manage formulary strategy, specialty/biosimilar utilization, and site-of-care steerage for infusions and high-cost specialty drugs.
• Build and continuously refine Victra's GLP-1 (weight-loss/diabetes) coverage strategy — eligibility criteria, utilization management, lifestyle-program pairing, and vendor point-solution evaluation — given GLP-1s are now one of the fastest-growing cost drivers for self-insured plans nationally.
• Run PBM RFPs on a disciplined cadence (typically every 2–3 years) using independent pricing benchmarks.

Plan Design & Network Strategy

• Redesign benefit tiers, networks, and steerage incentives (reference-based pricing, narrow/tiered networks, centers of excellence for high-cost procedures, bundled-payment arrangements) to shift utilization toward high-value care without shifting unreasonable cost to associates.
• Evaluate and rationalize point solutions (MSK, virtual care, fertility, diabetes management, second-opinion services) for real ROI versus fee-stacking.
• Partner with HR/Total Rewards on plan design changes that balance cost, competitiveness in a large hourly-retail workforce, and ACA compliance (eligibility measurement periods, affordability).

Risk, Stop-Loss & Financial Stewardship

• Own the annual stop-loss/reinsurance placement — specific and aggregate attachment points, captive or level-funding alternatives — in partnership with Treasury and outside brokers/actuaries.
• Build and maintain a high-cost claimant / large-case management program in coordination with the TPA's clinical team to reduce catastrophic claim severity.
• Develop the plan's annual financial forecast, IBNR estimates, and trend assumptions in partnership with FP report plan performance, savings realized, and risk exposure to the CFO and executive team.

Governance, Data & Compliance

• Serve as (or directly support) the plan's ERISA fiduciary function: ensure documented, defensible processes for evaluating vendor fees and compensation, consistent with heightened PBM/TPA fee-disclosure and fiduciary-duty scrutiny under CAA and 2026 PBM reform.
• Build claims data and analytics capability (independent of TPA/PBM-provided reporting) to identify cost drivers, benchmark against peer self-insured employers, and validate vendor-reported savings.
• Maintain compliance with the No Surprises Act, price transparency, mental health parity (MHPAEA), and RxDC reporting requirements.

Success Metrics

• Net medical/Rx trend held below national benchmark (typically 6–9% gross trend for self-insured plans) and, over time, below Victra's historical trend.
• Documented, verifiable savings of 3–5x the role's fully-loaded cost within the first 12–18 months, sustained annually thereafter.
• Successful RFP/renegotiation outcomes for TPA and/or PBM contracts with improved transparency terms and audit rights.
• Reduced per-employee-per-year (PEPY) cost trend and stop-loss loss ratio improvement.
• Clean SOX/ERISA fiduciary governance record with no unresolved audit findings.

WHAT WE ARE LOOKING FOR

Required Qualifications

• 10+ years in health plan strategy, benefits consulting, PBM/TPA account management, or health plan actuarial/underwriting roles, including direct experience with a self-insured (self-funded) employer plan.
• Demonstrated history negotiating PBM and/or TPA contracts and quantifying resulting savings.
• Deep working knowledge of stop-loss/reinsurance structures, ERISA fiduciary obligations, and current PBM transparency/compensation -disclosure requirements.
• Strong financial and analytical skills — comfortable building trend models, IBNR estimates, and ROI cases, and defending them to a CFO and Finance audience.
• Bachelor's degree in finance, health administration, actuarial science, or related field.

Preferred Qualifications

• Experience in multi-site retail, restaurant, or other large hourly-workforce environments.
• Professional designation such as CEBS, ASA/FSA, or health care management consulting background (e.g., Mercer, Aon, WTW, Milliman).
• Direct experience running competitive TPA or PBM RFPs from specification through implementation.
• Familiarity with reference-based pricing, direct-to-employer provider contracting, or captive stop-loss arrangements.

TRAVEL REQUIREMENTS

• Occasional travel to visit TPA/PBM finalist sites and attend industry forums.

WHY JOIN US

• Paid training and career development opportunities.
• Comprehensive health, dental, and vision insurance.
• 401k retirement plan.
• Tuition reimbursement.
• Employee discounts on Verizon services.
• Referral bonuses
• Career pathing opportunities.

EQUAL OPPORTUNITY EMPLOYER

We're proud to be an equal opportunity employer - and celebrate our employees' differences, regardless of race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, or Veteran status. Different makes us better.