Sr. Pharmacy Performance & Operations Specialist

The Sr. Pharmacy Performance & Operations Specialist is responsible for oversight, performance management, and operational execution of G.E.H.A’s FEHB and PSHB pharmacy programs. This role owns PBM performance monitoring, contractual compliance, and operational integrity, ensuring alignment with regulatory requirements and enterprise objectives. The position serves as a subject matter expert and primary liaison to the PBM, driving issue resolution, enforcing contractual obligations, and delivering data-driven insights to inform strategic decisions and optimize member outcomes. SKILLS Duties and Responsibilities: • Oversee PBM contract performance, ensuring alignment with contractual guarantees and federal program requirements. • Prepare, validate, and submit annual pharmacy benefit changes for FEHB and PSHB programs. • Develop division reports, dashboards, and executive-level presentation materials to monitor plan performance. • Manage PBM contractual credits, including reporting, validation, and quality assurance processes. • Monitor and enforce compliance with PBM contractual obligations and applicable regulatory requirements. • Serve as a subject matter expert for pharmacy benefits, including commercial benefit design and configuration. • Draft, review, and coordinate PBM performance-related penalty letters and enforcement actions. • Support contract governance activities, including performance reviews, issue escalation, and resolution tracking. • Monitor call center performance metrics, identify trends, and drive solutions to improve member experience. • Track eligibility changes and population shifts, assessing impact on pharmacy benefit performance and operations. • Identify contractual or operational gaps and develop corrective action plans to address shortfalls. • Review pharmacy-related Customer Success content to ensure accuracy, consistency, and alignment with benefits. • Respond to internal and external audit inquiries, providing documentation and ensuring audit readiness. • Validate production and pre-production claims accuracy, ensuring alignment with benefit design and contract terms. • Investigate and resolve complex pharmacy-related member issues and escalations. • Manage day-to-day pharmacy program operations, including implementation and administration of new initiatives. • Serve as the primary liaison to the PBM for operational issues, program implementation, and eligibility matters. • Coordinate cross-functional efforts with internal stakeholders to resolve PBM-related issues and drive performance improvement. • Perform other duties as assigned to support pharmacy program performance and operational objectives. Knowledge, Skills, and Abilities: • Education: Bachelor's degree in healthcare administration, Pharmacy, Business Administration, Public Health, or related field. • A minimum of 5 years of progressive experience in pharmacy operations, pharmacy benefit management (PBM), health plan operations, or federal health program administration (e.g., FEHB, PSHB) • FEHB/PSHB program knowledge: Familiarity with federal pharmacy benefit requirements and regulatory expectations. • Analytical and reporting skills: Proficiency in Microsoft Office Suite and ability to build dashboards, analyze trends, and interpret performance data. • Contract interpretation: Skilled in understanding and applying contractual terms to operational scenarios. • Problem-solving abilities: Capable of diagnosing issues, identifying root causes, and developing solutions. • Communication skills: Able to explain complex pharmacy concepts and decisions. • Attention to detail: Strong accuracy in reviewing claims, reports, and compliance documentation. • Cross functional collaboration: Ability to work with internal teams, PBM partners, and regulatory stakeholders. • Executive communication: ability to translate complex PBM, financial, and regulatory concepts into clear, actionable insights. Preferred Qualifications • Advanced pharmacy, healthcare, or business administration degree (e.g., MPH, MHA, MBA, PharmD). • Data visualization tools: Experience with Tableau, Power BI, or similar platforms. • Project management certification: PMP, CAPM, or equivalent. • Regulatory compliance experience: Familiarity with OPM, CMS, or other federal oversight bodies. • Process improvement training: Lean, Six Sigma, or similar methodologies. Work-at-home requirements • Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office. • A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required. • Latency (ping) response time lower than 80 ms • Hotspots, satellite and wireless internet service is NOT allowed for this role. • A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information How we value you • Competitive pay/salary ranges • Incentive plan • Health/Vision/Dental benefits effective day one • 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution • Robust employee well-being program • Paid Time Off • Personal Community Enrichment Time • Company-provided Basic Life and AD&D • Company-provided Short-Term & Long-Term Disability • Tuition Assistance Program While this is a remote opportunity, at this time G.E.H.A does not hire employees from U.S. territories or the following states: Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine. Please note that the salary information is a general guideline only. G.E.H.A considers factors such as (but not limited to) scope and responsibilities of the position, candidate’s work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer. The target hiring range for this position is $81,672 - $103,320 USD. At G.E.H.A, the current maximum salary for this role is $115,128 USD. While initial compensation may vary based on experience and qualifications, there is a path to work toward this top rate through performance and continued growth within the organization. G.E.H.A is headquartered in Lee's Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.