Director, Pharmacy Analytics

Job Title: Director of Pharmacy Analytics
Location: Remote/Hybrid
Department: Pharmacy / Payment Integrity
Reports To: VP of Payment Integrity

Job Summary:

The Director of Pharmacy will lead the pharmacy-related functions within SmartLight Analytics. This leadership role will focus on ensuring the accuracy, efficiency, and compliance of pharmacy claims processing, with a particular emphasis on identifying and preventing fraud, waste, and abuse (FWA) using advanced analytics. The Director will collaborate with cross-functional teams, including analytics, operations, technology, to develop and implement pharmacy strategies that optimize payment integrity, reduce costs, and enhance overall performance.

This position will also involve overseeing the design, development, and execution of pharmacy programs that support payer and provider partnerships, while building and developing pharmacy team.

Key Responsibilities:

Leadership and Strategy:

• Develop and execute the strategic direction for pharmacy operations within the company, with a focus on improving payment integrity and optimizing reimbursement accuracy to assist self-funded employers effectively manage their plans.

• Lead, mentor and develop a team of pharmacy professionals, pharmacy analysts, and operational staff to ensure alignment with organizational objectives.

• Work closely with senior leadership to shape the vision and goals for pharmacy-related payment integrity initiatives.

Pharmacy Payment Integrity and Claims Management:

• Utilize analytics to identify potential payment errors, overpayments, underpayments, and fraud within the pharmacy reimbursement cycle.

• Develop and implement solutions to reduce costs for clients in relation to pharmacy claims processing.

• Optimize PBM Rebate programs and incentives to benefit clients

• Review and recommend improvements to ASO PBM Contracts

Data Analytics and Reporting:

• Work with the data analytics team to develop and implement AI models and algorithms that identify trends, discrepancies, and opportunities for improving pharmacy payment integrity.

• Use advanced analytics tools (e.g., AI/ML, business intelligence platforms) to analyze pharmacy claims data, detect anomalies, and recommend actionable solutions.

• Develop and present comprehensive reports to leadership, stakeholders, and external partners detailing performance metrics, insights, and recommendations.

Regulatory Compliance and Industry Standards:

• Stay up to date with evolving healthcare regulations, pharmacy industry standards, and payer requirements to ensure compliance in all pharmacy-related processes.

• Ensure that pharmacy payment integrity initiatives align with government regulations (e.g., CMS, HIPAA), payer contracts, and industry standards.

Qualifications:

• Education:

• PharmD, with a Managed Care Residency preferred

• Experience:

• Minimum of 6 – 8 years of experience in pharmacy operations, healthcare payment integrity, or pharmacy benefit management (PBM), with at least 3 years in a leadership role.

• Strong expertise in pharmacy claims auditing, payment integrity processes, and fraud detection.

• Experience with pharmacy reimbursement models, pharmacy compliance, and healthcare regulatory frameworks (e.g., CMS, HIPAA).

• Background in using data analytics or business intelligence tools to enhance pharmacy claims management and payment integrity.

• Skills:

• Strong leadership, team building, and management skills.

• Advanced knowledge of pharmacy benefits, payment integrity, claims adjudication, and fraud prevention.

• Excellent problem-solving, critical thinking, and strategic planning abilities.

• Strong communication skills with the ability to present complex data and insights to both technical and non-technical stakeholders.

Key Competencies:

• Strong analytical mindset with the ability to identify patterns, trends, and anomalies in pharmacy data.

• Ability to drive change and implement process improvements based on data insights.

• Excellent interpersonal and communication skills, with the ability to work with cross-functional teams and external partners.

• High attention to detail and a commitment to quality and compliance.

• A proactive, solution-oriented approach to addressing challenges and improving operational efficiency.

Who is SmartLight Analytics

SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight works for self-funded employers to reduce the wasteful spend in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.