Pharmacy Manager, Benefit Operations - Emory Health Plan

Description The Pharmacy Manager, Benefit Operations (Emory Health Plan) serves as the primary operational liaison between the Emory Health Plan (EHP) Pharmacy division and the Pharmacy Benefit Manager (PBM).

KEY RESPONSIBILITIES:

Ensures accurate and timely implementation of all pharmacy benefit configurations, formulary and UM updates, specialty drug programs, and plan design elements. Provides day-to-day oversight, leads implementation cycles, validates system accuracy, and supports overall plan performance, financial stewardship, and member experience. Serves as the main contact for all PBM configuration activities and benefit builds. Reviews/approves PA criteria, clinical edits, copay rules, accumulators, NDC exclusions, and formulary updates. Conducts ongoing audit, testing, and documentation of all configuration elements, including NDC crosswalks and specialty drug rules. Leads daily/weekly/monthly operational touchpoints with the PBM to review performance and configuration changes. Investigates and resolves claim processing issues, benefit errors, and member escalations. Collaborates with Emory Specialty Pharmacy, Ambulatory Operations, and clinical teams to ensure alignment. Manages pharmacy configuration for open enrollment, new plan launches, mid‑year benefit updates, and special programs. Maintains project plans, timelines, testing cycles, and validation reports. Oversees approval and tracking of PBM change requests and configuration tickets. Reviews formulary placement, exclusions, and UM rule changes for accuracy and impact. Translates clinical policies into system edits in partnership with Pharmacy Clinical Programs. Maintains a centralized formulary + UM rules source of truth for governance and compliance. Validates rebate classifications, NDC/J‑code crosswalks, specialty lists, and accumulator logic. Ensures compliance with CMS, DOL, ERISA, and internal EHP audit requirements. Partners with IT, legal, and compliance to ensure secure and accurate data flow. Monitors daily/weekly adjudication dashboards, denied‑claim trends, and high‑cost drug utilization. Identifies root causes of configuration or operational issues and recommend improvements. Works with analytics teams to assess benefit design impact and trend drivers. Provides expert guidance on benefit interpretation and PBM operations to internal stakeholders. Collaborates with vendor management, clinical programs, specialty pharmacy, and member services. Presents updates to EHP leadership, governance committees, and benefit oversight groups.

MINIMUM QUALIFICATIONS:

Doctor of Pharmacy (PharmD) from an accredited School of Pharmacy. 3+ years of clinical pharmacy, managed care, or health system experience. Demonstrated leadership experience within a pharmacy setting, including oversight of clinical, operational, or administrative function. Strong knowledge of drug therapy, formulary management, evidence evaluation, and population health principles. Experience working with PBMs. Experience managing ongoing external vendor relationships. Ability to engage effectively with patients, vendors, physicians, clinical leaders, and multidisciplinary teams. Strong analytical and communication skills are important. Strong project management and organizational skills are essential.

PREFERRED QUALIFICATIONS:

Completion of PGY1 residency preferred in pharmacy practice, managed care, ambulatory care, population health, or pharmacotherapy. Prior experience within a health plan, PBM, IDN, or specialty pharmacy setting. Experience with utilization management criteria, project management, outcomes measurement, or quality improvement programs. Familiarity with medical + pharmacy benefit integration and specialty drug management. NOTE: Position tasks are generally required to be performed in‑person at an Emory University location. Remote work from home day options may be granted at department discretion. Emory reserves the right to change remote work status with notice to employee. Additional Details Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law. Emory University does not discriminate in admissions, educational programs, or employment, including recruitment, hiring, promotions, transfers, discipline, terminations, wage and salary administration, benefits, and training. Students, faculty, and staff are assured of participation in university programs and in the use of facilities without such discrimination. Emory University complies with Section 503 of the Rehabilitation Act of 1973, the Vietnam Era Veteran's Readjustment Assistance Act, and applicable executive orders, federal and state regulations regarding nondiscrimination, equal opportunity, and affirmative action (for protected veterans and individuals with disabilities). Inquiries regarding this policy should be directed to the Emory University Department of Equity and Civil Rights Compliance, 201 Dowman Drive, Administration Building, Atlanta, GA 30322. Telephone: View phone number on click.appcast.io (V) | View phone number on click.appcast.io (TDD). Emory University is committed to ensuring equal access and providing reasonable accommodations to qualified individuals with disabilities upon request. To request this document in an alternate format or to seek a reasonable accommodation, please contact the Department of Accessibility Services at View email address on click.appcast.io or call View phone number on click.appcast.io (Voice) | View phone number on click.appcast.io (TDD). We kindly ask that requests be made at least seven business days in advance to allow adequate time for coordination. #J-18808-Ljbffr JobRx, Inc.