Director, Pharmacy Benefit Management Operations

Pharmacy Benefit Management (PBM) Irvine, California


Looking for a job that positively impacts employees’ lives?

Imagine the personal satisfaction of knowing that the work you do makes a difference. Working in the health benefits industry means your daily efforts go toward ensuring that employees and their family members have access to health care and medications when they need it. For nearly 25 years, Pinnacle Claims Management has been providing self-insured employers affordable health benefit solutions to keep their staff and their business thriving. Under the “Pinnacle” brand, we offer third-party benefits administration, health management services, pharmacy benefit management, general underwriting and print and transaction solutions. When you work for one of our Pinnacle-branded companies, you will join a team of caring professionals who are committed to serving our clients in a variety of capacities including claims processing, customer service, account management, eligibility, finance, and more. We serve a number of industries including school districts, municipalities and manufacturers.

But wait, there’s more!

As a Pinnacle employee, your focus will always be to ultimately serve our valued self-insured clients. For your efforts, we offer career stability, a competitive salary, friendly staff and a pleasant work environment. You will be part of the dynamic health benefits industry and work alongside other compassionate hardworking people who are committed to applying their talents to serving our clients. When you join a Pinnacle-branded company, you become part of an even larger organization – the Western Growers Family of Companies, a California-based entity that has been around for nearly 100 years.

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The Director of PBM Operations & Services reports to the Vice-President of Pharmacy Benefit Manager Services. The incumbent will be responsible for planning and directing all aspects of prescription benefit management (PBM) functions, including PBM claims & plan management, PBM customer service, PBM client management, PBM consulting resources, Rx audits & fraud/abuse identification and drug utilization review programs. This position oversees all subcontracted prescription programs and services including Specialty Rx, Mail Order, Formulary Management and Pharmacy network management. Incumbent is responsible for the daily operations of the pharmacy benefit staff which include managing and mentoring direct reports; Supervisor of PBM Operations, Pharmacy Benefit Analyst, Benefit Configuration Specialist. They will monitor the application of pharmacy benefit management system including policies and procedures and information flow. Additionally, they will approve personnel activity concerning hiring, training/development and evaluation of staff performance.


• Bachelor of Science/Bachelor of Art Degree and/or seven (7) plus years’ experience in directing/managing prescription drug card operations and PBM services minimum, MBA preferred.
• PharmD preferred.
• Knowledge of pharmacy claims processing processes, drug claim pricing and National Council for Prescription Drug Programs (NCPDP) standards.
• Exceptional ability to communicate verbally and in writing with staff, clients and management personnel.
• Familiar with a variety of health benefits insurance carrier concepts, practices and procedures.
• Excellent negotiation skills.
• Proven strategic ability to improve standards and operational functions and procedures.
• Ability to work with all levels of management and in a team environment.


PBM Operations

• Build and maintain quality programs by monitoring established metrics, based on root cause analysis, formulating corrective action and providing feedback to leadership and staff.
• Ensure successful management and execution of business goals.
• Develop procedures and policies to enhance and improve PBM operations and services.
• Ensure regulatory compliance at the state and federal level and assist in preparation for inspections and audits.
• Oversees the application of pharmacy management system including policies and procedures and information flow.
• Manage the development of the new pharmacy benefit management system.
• Assure the documentation of processes and maintenance of procedures to ensure high quality data input/capture into the pharmacy, inventory and distribution processing system.
• Partner across the organization and with other pharmacy site(s) to develop and implement solutions designed to improve member/client satisfaction and streamline processes between functions for improved service delivery.
• Prepare and present production, audit statistics and customer service metrics on a monthly and quarterly basis to the appropriate management boards for WGAT and PCMI.
• Provide ongoing training education and communications to staff regarding operations and compliance.
Vendor Relations
• Manage formulary placement and administrative fees within the drug rebate program.
• Act as the liaison for pharmacies and wholesalers to negotiate reimbursement and fees.
• Manage third-party service provisions and programs to ensure optimal vendor engagement and performance; managing contractual expectations, defining and collecting performance metrics, reviewing processes and workflows to optimize each vendor relationship and offering.

Management & Leadership

• Develop, manage, and lead a team of 3A+ self-accountable professionals.
• Develop a culture of real, personal accountability by modeling the behavior that defines it.
• Instill a culture of safety and expectation, within your respective area/s.
• Require direct reports to hold themselves accountable to high standards of, performance and personal conduct, in a clear, helpful, straightforward way.
• Conduct one-on-one conversations with every direct report, on a quarterly basis, focused on their 3A+ capabilities, impact, and effort.
• Make decisions and choices, impacting staff, by using the selection and hiring, clarifying roles and objectives, managing performance, correction & discipline and termination steps as outlined in the “Outward Mindset Skills for Leaders” guide.


• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
• All other duties as assigned.

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to travel to both indoor and outdoor areas that can vary in exposure and temperature. The employee is frequently required to operate a motor vehicle, use objects, tools, or controls, and/or required to lift up to 50lbs. The noise level in the work environment is usually moderate.