Managed Care Pharmacy Analytics

The Managed Care Pharmacy Analytics leads two core components of our pharmacy product. First, in an externally facing, subject-matter-expert capacity, this role serves as the pharmacist voice on client calls, discussing payment integrity findings, creating and telling the story with analytics, and potentially acting as the clinical lead representing clients through PBM RFPs. Second, the this role acts as the clinical subject-matter expert on model development, ensuring payment integrity models make clinical and operational sense. Across both, this role brings enough command of PBM operations and analytics to drive realistic, actionable recommendations, partners closely with the data science team, and speaks to findings independently with clients and PBMs. This Position also collaborates with cross-functional teams, including product, account management, legal advisors, operations, and technology, to develop and implement pharmacy strategies.

Key Responsibilities:

Client PBM Guidance:

• Serve as the primary pharmacy/clinical subject-matter expert on client calls, discussing payment integrity findings and translating analytics into clear, actionable stories for clients.

• Bring a working knowledge of PBM operations, including how claims adjudicate and how pricing/rebate terms are administered in practice.

• Potentially act as the clinical lead for PBM RFP evaluations and collaborating with the analytics team to ensure contract and financial guarantee findings are clinically and contractually sound.

Clinical Model Development & Payment Integrity:

• Partner with the data science team to shape and validate the clinical logic behind pharmacy models and AI/algorithm development, including formulary and utilization management rules, drug classification, specialty/LDD designations, and payment integrity trend and anomaly detection.

• Ensure new and existing analytic capabilities make clinical and operational sense before they enrich our pharmacy products or reach other departments.

• Ensure payment integrity findings are integrated into the broader PBM strategy and client-narrative, rather than treated as a standalone deliverable.

Strategy & Cross-Functional Partnership:

• Contribute to the strategic direction of the pharmacy offering, with a focus on improving client PBM knowledge, payment integrity, and analytics outcomes.

• Work closely with leadership to shape the vision and goals for pharmacy-related strategy, PBM operations, and payment integrity initiatives.

• Collaborate with cross-functional teams, including data science, account management, legal advisors, operations, and technology, to develop and implement pharmacy strategies.

Regulatory Compliance and Industry Standards:

• Stay current on evolving healthcare regulations, pharmacy industry standards, and payer requirements.

• Ensure PBM strategy and payment integrity work align with government regulations (e.g., CMS, CAA) and payer contract requirements.

Qualifications:

• Education:

• PharmD, with a Managed Care Residency preferred

• Training in analytic methods and/or pharmacy data analysis recommended

• Experience:

• Minimum 6–8 years of experience in pharmacy benefit management, with meaningful client-facing or PBM-facing experience.

• Minimum of 3 years’ experience in analyzing pharmacy claims data, especially payment integrity issues.

• Demonstrated understanding of how PBM operations work in practice, e.g., how claims adjudicate, how pricing/rebate terms are administered, and where contract terms and real-world operations diverge. This is often gained through roles such as trade/rebate contract negotiation, account management, clinical data science/analytics, or PBM clinical/claims operations.

• Demonstrated ability to interpret PBM contract terms (pricing guarantees, rebate arrangements, definitions) and connect them to clinical and financial impact.

• Comfortable partnering closely with an analytics team and speaking independently to their findings, without personally performing every underlying analysis.

• Skills:

• Strong executive presence; able to represent SmartLight independently in front of clients and PBMs.

• Advanced knowledge of pharmacy benefits, PBM contracting and operations, claims adjudication, and formulary/utilization management.

• Comfortable engaging with data science teams on model logic, clinical assumptions, and validation, without requiring a technical/data science background.

• Excellent communication skills, translating complex clinical and contractual findings for technical and non-technical audiences alike.

• Strong collaboration and partnership skills, working effectively across teams without direct authority.

Key Competencies:

• Strong analytical and clinical judgment, with the ability to identify patterns, trends, and risk in pharmacy contract, claims, and operational data.

• Ability to drive change and influence PBM discussions and outcomes based on data and clinical insight.

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

• A proactive, solution-oriented approach to client and PBM challenges.

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.

Originally posted on Himalayas