Job Summary:

This position is responsible for overseeing the performance management and optimization of Government Program Pharmacy Benefits as administered by Cigna and its contracted vendors, with specific focus on Pharmacy Benefit Manager (PBM) performance and internal work streams.

This position will have a concentration/focus in key areas:

• Operational Capabilities (development and refinement)


• Ensuring business process and Government compliance


• Business development (develop solutions and services Pharmacy and Product Operations)


• Client/beneficiary growth and retention


• Influencing profitability and revenue generation


• Operating expense reduction initiatives

Core Responsibilities:

• Manage Pharmacy Post-Payment Review and PBM metrics to ensure correct application of Center for Medicare/Medicaid Services (CMS) guidance and business and financial objectives. This includes oversight of PBM performance measures impacting beneficiaries' access to care, patient safety, proper application of clinical programs, beneficiary/prescriber service standards, internal/external reporting, and applicable government/vendor contractual requirements.


• Lead a team of associates that specialize in principles of Government Program Pharmacy Benefit administration utilizing performance improvement methodologies to drive program performance optimization.


• As a member of the Operations leadership team, contributes in the execution of the strategic vision, evaluating current performance and driving operational initiatives.


• Administer Pharmacy Post Payment Claims Review to ensure claim adjudication correctness and timely reject resolution where necessary. Reviews include but are not limited to: review paid and rejected claims /rejected claim resolution/transition fill management/protected drug class review/high dollar claims/B vs D reject claim resolution/RTS/EOB validation/MIC review, Prior Authorization appropriate outcomes, Vaccines, DUR, etc.


• Develop, collect, validate, and analyze key indicator metrics around all areas of program performance supporting compliance and business objectives to identify needed corrective actions or performance improvement opportunities


• Identify organizational and compliance risks and issues, analyze required operational performance actions and activities, develop and initiate required corrective actions to mitigate risk, and monitor to completion


• Develop and administer processes that support cost reduction, improved NPS scores and increased compliance by utilizing Continuous Quality Improvement (CQI) methodology.


• Conduct ongoing oversight of claim adjudication vendor for contract completeness, accuracy/adequacy, and SLAs/PGs


• Coordinate with internal CHS departments to implement and administer CMS guidance and/or PBM programs and changes


• Identify, lead and drive strategic operational initiatives that influence MAPD/PDP profitability and STARS performance


• Monitor to ensure government required communications and file submissions are timely, accurate and consistent with CMS expectations


• Develop and maintain collaborative partnership with other operational areas across the enterprise and with strategic external partners to ensure a holistic customer service approach that drives business outcomes.


• People Management, consistent check-ins, mentoring and coaching


• Build and promote an environment that represents and values all aspects of diversity


• Create and maintain an environment that motivates employees to achieve their full potential

Minimum Qualifications:

• Bachelor's degree or equivalent work experience


• 8-10 years in a Pharmacy role and 5 years in leadership position


• Preference given to Medicare/Medicaid and PBM experience.


• Deep operational understanding of Medicare and Medicaid benefit administration in a clinical pharmacy setting with understanding of CMS Chapter 6 Formulary Administration requirements


• Business Process Improvement-oriented (process design, workflow and process mapping, etc.)


• Ability to analyze the competitive landscape and identify industry key market, clinical, cost, and emerging practice trends


• Adaptable, flexible, and able to lead and manage the organization through change


• Goal oriented and personally accountable; resourceful and self-directed


• Ability to problem solve, identify and remove roadblocks, triage and prioritize issues


• Ability to effectively collaborate across the organization


• Demonstrated success in people leadership, including an exceptional ability in connecting the day-to-day work to broader organizational goals.


• Exceptional communications (written/verbal) and interpersonal skills

Preferred Requirements: At least five years' experience establishing and implementing within Operations to support Federal and State regulations. Prior experience in developing, updating, and communicating policies and standard operations procedures. Experience with remediation activities and operations recovery. Experience in effective engagement with strategic partners. Experience in leading and managing initiatives in a matrixed environment

Core Competencies:

• Strategic Focus and Agility

• Operational Discipline and Enterprise Mindset

• Negotiation, Influential Leadership and Motivating Others

• Driving Change

• Managing Vision and Purpose

• Delivering Consistent Results in Ambiguous Circumstances

• Customer Centric Thinking

• Cross-Cultural Agility

Technical/Functional Competencies:

• Understanding Client/Customer Needs and Interaction

• Business Development and Customer Segmentation/Targeting

• Financial Acumen and Effectiveness Measures

• Visioning and Strategy Execution and Operations

• Health Service Products and Legal / Regulatory Environment

• Pharmacy Informatics

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an annual salary of 101,600 - 169,400 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna .

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

Cigna has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.