Tufts Health Plan Manager, Pharmacy Operations – Commercial & Medicaid Job in Watertown, MA


We enjoy the important work we do every day on behalf of our members.

Job Summary

Under the administrative oversight of the Director, Pharmacy Operations, the Manager of Pharmacy Operations is responsible for the oversight, development, implementation, and maintenance of Point32Health (P32H) systems, as well as policies and procedures related to pharmacy operations. Responsibilities also include oversight of the Pharmacy Program Specialists and Coordinators responsible for supporting the enterprise call centers. This individual serves as the primary liaison to operational counterparts at the pharmacy benefit management (PBM) vendors to ensure accuracy and execution of pharmacy-related initiatives, programs, and benefit designs developed and implemented by the Pharmacy Department for Commercial, and Medicaid. This individual collaborates with key stakeholders across P32H to develop and support administrative and medical cost savings opportunities. This individual manages the work of the Pharmacy Operations Team to ensure that business results are successfully achieved. This individual interprets and complies with regulatory, compliance, and accreditation requirements for pharmacy operations and programs. As a Manager in the Pharmacy Department, this individual is a strong leader who engenders confidence among internal and external constituents.

Job Description

Pharmacy Benefit Manager (PBM) oversight and performance

  • Define, implement, and continuously monitor the performance of pharmacy operations to meet the needs of members, providers, and key stakeholders for Commercial, QHP, and Medicaid
  • Manage PBM operational performance, process improvements, and service issue resolution
  • Ensure metrics and service standards are met to optimize customer experience
  • Ensure PBM performance guarantees are met
  • Recommend enhancements and refinements as needed to mitigate compliance risks
  • Serve as primary liaison to PBM operations counterparts, providing oversight with current and prospective process automation and services
  • Develop and implement standard operating procedures, holding PBM accountable for all operational functions in accordance with contractual agreement

Performance Management

  • Develop, monitor, and maintain key performance indicators including, but not limited to: operational effectiveness, quality assurance/regulatory compliance, and departmental service level agreements
  • Oversee the ongoing evaluation of current operational strategy and programs, directing improvements and process reengineering to ensure customer satisfaction and operational efficiency and effectiveness
  • Prioritize the department’s work (programs, services, policies, operations)
  • Develop resource plans for planned and unplanned work related to changes in the business environment, resource availability, etc.
  • Manage maintenance of business and day-to-day issues. Ensure appropriate testing is completed. Analyze root causes and identify solutions of issues. Establish actionable next steps and project accurate completion dates.
  • Monitor progress and team productivity, report overall status/measures of success, and identify issues and risks
  • Collaborate with other departments within Pharmacy Services (e.g., Clinical Pharmacy, Utilization Management, Reporting, Contracting) to develop and implement annual requirements and cost-savings initiatives as well as track results
  • Collaborate with departments outside of Pharmacy such as:Member and Provider Services; Enrollment, Premium Billing, Plan Benefits; Business Implementation; Sales, Marketing & Product Strategy; and Compliance

Annual plan benefit changes

  • Scope, plan, and implement formulary and benefits changes which may include:changes driven by Product Strategy ; regulatory/compliance changes (e.g., state mandates, federal mandates); custom requests from employer groups
  • Assess impact of proposed changes on members
  • Oversee communications to members and providers
  • Ensure pharmacy operations goals are appropriately aligned with P32H business priorities

Process improvement

  • Proactively identify and prioritize areas for process improvement to achieve operational excellence
  • Scope, plan, and implement process improvements, including c hange management and influencing stakeholders

Strategic initiatives

  • Serve as key member of pharmacy management team, providing input to future pharmacy management strategy and strategic operating priorities
  • Participate in and chair task forces or committees concerning pharmacy initiatives
  • Ensure that pharmacy operations goals are appropriately aligned with THP business priorities
  • Scope, plan, and execute strategic initiative projects


  • 7-10 years of progressive business experience in health care and/or managed care. Experience in health care service delivery, customer relations, and regulatory/compliance. Possess a fundamental knowledge of health care delivery systems, managed care. Experienced with large-scale project implementation and project management is desired
  • 7-10 years of management experience supervising high-level professionals required, with demonstrated success in program development and execution
  • Experience with healthcare operations, pharmacy benefits, formulary administration, and data analysis
  • Must be able to work cooperatively as a team member with varying levels of staff throughout the organization. Must ensure compliance with confidential data and adherence to corporate compliance policy
  • Strong planning, problem solving, analytic and change management skills. Ability to prioritize and manage competing issues and to effectively lead in a matrix environment.
  • Strong presentation skills as well as highly-developed verbal and written communication skills.
  • Excellent quantitative skills and attention to detail; strong analytic background preferred
  • Excellent leadership ability to guide and inspire others, encourage high standards, and exemplify those standards. Requires strong skills at developing teamwork involving a multidisciplinary approach with staff and numerous departments throughout the company
  • Requires a high degree of initiative, proactivity, and excellent judgment and decision-making ability. Ability to handle politically-sensitive situations and interact with a wide range of professionals. Requires the ability to work effectively in an extremely complex and often politically-charged environment, working with numerous interdepartmental contacts to problem solve and resolve complex provider issues
  • Strong oral and written communication skills, working effectively with internal/external stakeholders including regulatory agencies.
  • Requires excellent analytical skills necessary to formulate operational methodologies and analyze data. Must be adaptable to change and work in ambiguous situations while maintaining demeanor and performance under stress. Must possess the ability to critically assess new programs and policies and their impact on quality of operations. Requires a strong presence that will engender confidence among internal and external constituents.

What we build together changes our customer’s health for the better. We are looking for talented and innovative people to join our team. Come join us!

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