Operations Lead - Government Pharmacy Benefit Management

Position Overview

• Location Type: Remote
• Job Type: Full-time
• Salary: Not specified

RxSense is a leading healthcare technology company delivering innovative solutions for pharmacy benefits and prescription savings. Our enterprise platform brings transparency, flexibility, and efficiency to pharmacy benefit management, helping clients streamline operations and enabling consumers to save on prescriptions. By integrating intelligence across the pharmacy ecosystem, RxSense makes cost-effective healthcare more accessible. Whether for PBMs, pharmacies, or individuals, our solutions help modernize operations, reduce costs, and improve outcomes.

RxSense also owns and operates SingleCare, a free prescription savings service that offers consumers access to consistently low prices on prescription drugs. Through its partnerships with the country’s largest pharmacies and grocers, including CVS, Walgreens, Walmart, Kroger and Albertsons, SingleCare improves access and adherence to affordable medications and has helped millions of Americans save over $11 billion on their medications.

RxSense is a great place to work! Our company has earned several prestigious awards, including Fast Company’s Most Innovative Companies, Forbes’ Top Startup Employers, Modern Healthcare’s Best Places to Work in Healthcare, and Inc’s Best in Business and Best Workplaces.

The Operations Lead will serve as the core leader for building and managing our PBM operational infrastructure and workflows, with a specific focus on government healthcare programs including Medicare Part D, Medicaid, and ACA marketplace plans. This role is essential for establishing scalable, efficient operational foundations while ensuring seamless integration of compliance and clinical requirements across all service delivery channels.

Requirements

• Experience in PBM operations, specifically with government healthcare programs (Medicare Part D, Medicaid, ACA marketplace plans)
• Understanding of CMS, state Medicaid, and ACA regulatory requirements
• Ability to design and implement operational infrastructure and workflows
• Strong leadership and collaboration skills
• Experience with prescription drug claims processing systems and formulary administration

Responsibilities

• Operational Infrastructure Development:
  • Design and implement comprehensive PBM operational infrastructure and workflows for government healthcare programs.
  • Establish service delivery standards that meet or exceed CMS, state Medicaid, and ACA regulatory requirements.
  • Develop operational policies, procedures, and performance metrics aligned with federal and state program requirements.
  • Create staffing models and organizational structures to support efficient service delivery across all channels.
  • Lead benefit, formulary, and network implementations.
• Transaction Processing & Claims Management:
  • Oversee prescription drug claims processing systems for Medicare Part D, Medicaid, and ACA plans.
  • Implement and manage formulary administration, including tier structures and utilization management programs.
  • Develop mail-order pharmacy operations and specialty pharmacy services.
• Cross-Functional Leadership:
  • Serve as cross-functional leader to prioritize development needs across departments.
  • Collaborate with compliance teams to ensure operational frameworks incorporate all regulatory requirements.
  • Partner with clinical teams to integrate medication therapy management (MTM) services.

Application Instructions

• Not specified