Director – Benefit Design and Requirements

Role Overview

• Serve as the senior PBM subject matter expert and strategic advisor to clients, consultants, and internal leadership across implementation and ongoing benefit strategy
• Lead high-impact discovery and design sessions with clients, consultants, and cross-functional stakeholders to define complex benefit structures, including formulary strategy, cost-sharing models, accumulator logic, specialty tiers, step therapy protocols, and regulatory considerations
• Shape and influence client benefit strategies by aligning industry best practices, market trends, and AffirmedRx platform capabilities
• Anticipate risk and proactively address gaps in benefit design or documentation, partnering with senior implementation and account leadership to drive resolution
• Provide executive-level oversight and guidance on benefit configuration, ensuring alignment between intended design and system build
• Act as the escalation point for complex benefit design or configuration issues, driving resolution through deep expertise and cross-functional collaboration
• Influence best practices for benefit setup within the adjudication platform, ensuring consistency, scalability, and accuracy
• Lead and drive technology change initiatives related to adjudication systems and benefit capturing enhancements, partnering with IT and platform teams to evaluate, prioritize, and implement system improvements that reduce configuration error, improve accuracy, and scale with organizational growth
• Own the testing strategy and validation framework for PBM benefits, ensuring comprehensive coverage of complex plan structures and edge cases
• Oversee end-to-end testing validation, ensuring benefit logic, cost-share structures, accumulators, and compliance requirements function as designed
• Drive cross-functional alignment during UAT cycles, ensuring efficient defect resolution and timely remediation
• Provide executive summaries of go-live readiness, including risk assessments, issue tracking, and mitigation strategies
• Ensure all implementations meet the highest standards of accuracy, compliance, and client expectations prior to go-live
• Build and lead the Benefit Design & Requirements function, including defining team structure, hiring strategy, and capability roadmap
• Hire, coach, and develop a high-performing team, establishing clear roles, expectations, and career progression pathways
• Establish KPIs and performance metrics to measure quality, efficiency, and client outcomes
• Drive continuous improvement initiatives based on implementation retrospectives, root cause analysis, and client feedback
• Ensure all processes and documentation meet regulatory, audit, and contractual compliance requirements
• Partner with senior leadership to align function priorities with broader organizational goals and growth strategy

Requirements

• 10+ years of experience in pharmacy benefit management (PBM), health plan, or specialty pharmacy operations with direct exposure to benefit configuration or plan design
• Bachelor’s degree in Business Administration, Healthcare Administration, Health Informatics, or Pharmacy or related field
• 5+ years of people leadership experience, including hiring, developing, and managing teams in a PBM, health plan, or pharmacy operations environment
• Demonstrated experience building and scaling high-performing teams from the ground up, while establishing and operationalizing standardized processes, procedures, and governance frameworks.
• Demonstrated expertise interpreting and translating PBM benefit structures, including formularies, prior authorization, step therapy, accumulators, and cost-sharing designs, into system-ready requirements
• Proven experience designing and executing benefit or claims testing in a managed care, PBM, or pharmacy technology environment
• Exceptional written communication skills with the ability to produce clear, detailed requirements and testing documentation
• Strong client-facing consultative skills; ability to build rapport, ask probing questions, and manage competing stakeholder expectations with professionalism
• High analytical aptitude and comfort with ambiguity; can synthesize complex, inconsistent source material into clean, actionable deliverables
• A builder’s mindset, energized by creating something from scratch and motivated by the opportunity to establish a function others will grow within
• Exposure to regulatory frameworks governing pharmacy benefits (e.g., CMS guidelines, ACA compliance, ERISA) preferred
• Hands-on experience building or configuring benefits within a PBM or pharmacy adjudication platform is a strong plus
• Willingness to travel up to 25%

Benefits

• To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
• To work in a culture where people thrive because when OUR team thrives, OUR business thrives
• Competitive compensation, including health, dental, vision and other benefits