Job Description

A bit about this role:

As the Drug Trend Management Pipeline Development Senior Manager, you work a standing book of drug cost, safety, and integrity opportunities across Part B and Part D. Every item in it is a pattern across a group of members, and your job is to dig in and figure out which ones are worth solving for. You work out whether the pattern is real, what the opportunity is worth, whether anyone is already on it, and what kind of problem you're looking at. The ones that hold up, you build a case for. The ones that don't, you kill fast, with evidence, and move on.

Questions you may find solutions to include:

• How do you tell a real pattern from an artifact of how the data was pulled, and what is enough evidence to kill an opportunity and move on with confidence?
• When a Part B buy-and-bill pattern and a related Part D dispensing pattern point at the same problem, how do you see them as one opportunity instead of two unrelated findings?
• How do you tell a fixable waste pattern apart from a bad actor early enough that one goes to a policy fix and the other goes to investigation?

You are the analytical backbone that stitches a set of organizational capabilities into one response. Few people will see the whole board the way you do. A pattern that holds up might call for a utilization management (UM) criteria change, a policy update, new claim edit, coordination with our PBM or network partners, or a referral to the special investigations unit (SIU). Working out which lever fits, and making the case to the colleague who holds it, is what turns a finding into impact. The sharpest people in this seat notice what the book failed to surface and shape the future detection capabilities.

You will report to the Director, Clinical Pharmacy.

Responsibilities and Impact will include:

• Work the book. Evaluate surfaced opportunities one at a time. Pressure-test the signal: is the pattern real or an artifact of how the data was pulled, is the population correctly defined, is the spend real (net of rebate and net of what we already control), is something already in flight against it?
• Build the clinical and financial case. For opportunities that survive, assemble the clinical rationale (labeling, compendia, guidelines, comparative efficacy, safety and member-impact considerations) alongside the financial characterization. This is the depth we are hiring for. It is what makes an opportunity credible to the person who has to act on it.
• Form the hypothesis and find the owner. Characterize what kind of problem you are looking at and propose where the lever is. Then bring it to the function that holds that lever and make the case. You are not routing work to obligated recipients; you are convincing colleagues that there is something here worth their capacity. Flag dual- or multiple-natured opportunities rather than forcing them into one lane, and know before you walk in what UM, payment integrity, or SIU each need from you.
• Close the loop upstream. Feed false positives, near-misses, and pattern types that never pan out back into the detection process. Your judgment on what was worth pursuing and what was not is the training signal that makes our detection capabilities sharper over time, and that is how the work stays tractable as the book grows. Track why opportunities die, so the work compounds instead of repeats.
• Grow into the pipeline over time. As you prove your judgment on the evaluation work and your feedback measurably sharpens detection, you can take on more of how opportunities are produced and prioritized.

Required skills and experience:

• Deep expertise and immersion in the pharmacy domain, with a proven ability to apply this knowledge to drug cost, safety, and integrity opportunities.
• At least 5-8 years of experience in managed care pharmacy, utilization management, drug trend, or program integrity, with meaningful Part B and Part D exposure.
• Population-level analytical instinct. You think in cohorts and trends, not just individual charts. The unit of work is a pattern across many members, and you know how to reason about a group rather than one member at a time.
• Medicare regulatory fluency. You know what is permissible before you propose it: protected classes, negative formulary change rules and CMS submission timing, transition fill, the Part B versus Part D coverage boundary, appeals implications. In this role regulatory knowledge is a triage skill. It is how you avoid spending a colleague's capacity on a solution that was never going to be allowed.
• Hands-on with standard claims data. You work directly with pharmacy (NCPDP, GPI, DAW, NDC) and medical (HCPCS, buy-and-bill, units billed versus administered) claims to verify, characterize, and size a pattern yourself rather than waiting on someone else's analysis.
• Strong communication. You have to make a case, in writing and in the room, to someone who never saw the signal and has competing priorities. It is the most predictive skill in this role.
• Breadth over depth, outside the clinic. You do not need to be an actuary, a data scientist, or an investigator. You need to know enough about each to know what they need, what they can offer, and when to bring them in.
• Aptitude to grow. Evidence that you are a lifelong learner: you have built your own query library, automated something manual, or picked up a tool nobody assigned you. This is how we will read readiness to grow into the pipeline side of the role over time.
• Improves the process from inside it. You have made the work you were doing better, not just executed it well.

Desired skills and experience:

• Experience building or working alongside detection, suspecting, or FWA models, and a pragmatic view of agentic or LLM-assisted tooling
• Enough familiarity with payment integrity, SIU, or actuarial workflows to know what each needs from an opportunity before you bring it to them
• Rigor with data: you understand how open versus closed periods affect the read and how denominators shift, and you think in ranges rather than false precision
• Understanding of the matrix organizational patterns within a health plan, MA-PD plan sponsor, or PBM setting
• Deep domain expertise in drug trend management and pharmacy operations; while clinical credentials such as a PharmD are valued, they are not required.

Salary Range: $110,000 - $172,000 annually

#LI-REMOTE

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.