Business Change Director - CarelonRx PBM Operations Management

Anticipated End Date:

2026-05-04

Position Title:

Business Change Director - CarelonRx PBM Operations Management

Job Description:

Business Change Director - CarelonRx PBM Operations Management

Location: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. 

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Business Change Director is responsible for working with management to identify and implement varied projects, programs and plans that support achievement of business unit and enterprise goals, with a strong emphasis on Medicare Pharmacy Operations and benefit strategy execution. This role serves as a critical subject matter expert (SME) leading end-to-end benefit configuration, validation, and implementation processes aligned to CMS requirements, ensuring accurate adjudication of pharmacy claims and successful go-live for new plan year initiatives.

How you will make an impact:

• Serves as the primary Medicare pharmacy benefit SME, partnering with health plan product, clinical, and PBM/vendor teams (e.g., CVS) to interpret benefit intent and translate into accurate system configuration and execution.

• Leads end-to-end benefit build lifecycle including documentation, CMS submission support, configuration logic, testing, validation, and promotion to production for Medicare pharmacy benefits.

• Identifies potential issues, impacts to adjudication logic, and scope changes, and drives rapid resolution for critical, time-sensitive production or pre-production issues.

• Leads efforts to identify and implement best practices related to Medicare pharmacy benefit design, PBM operations, and claims adjudication processes.

• Identifies impacted parties, business partners, and resources required across cross-functional teams including product, clinical, compliance, and vendor partners.

• Develops and designs processes and systems that ensure accurate benefit setup, regulatory compliance, and operational readiness for annual bid and go-live cycles.

• Designs methods for integrating benefit configuration processes across systems, vendors, and internal teams to ensure seamless execution.

• Provides process, project, and change management methodology coaching/consulting support with a focus on highly complex, regulatory-driven initiatives.

• Leads prioritization and execution of benefit-related initiatives tied to CMS deadlines and annual Medicare bid cycles.

• Provides expertise in culture/change management activities within a fast-paced, high-accountability environment with critical deadlines (e.g., 1/1 go-live).

• Supports execution of the operating plan with accountability for accuracy of benefit logic, successful implementation, and operational readiness.

Minimum Requirements:

Requires a BA/BS in a related field and minimum of 10 years managing mid to large-scale change/project initiatives; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities, and Experience:

• Deep expertise in Medicare Part D pharmacy benefits including benefit design, formulary strategy, CMS (Centers for Medicare & Medicaid Services) regulatory requirements, and experience supporting Medicare bid submissions with the ability to translate benefit intent into operational and system requirements strongly preferred.

• Strong knowledge of Pharmacy Benefit Manager (PBM) operations, including vendor partnership (e.g., CVS or similar), claims adjudication processes, and end-to-end benefit configuration lifecycle (documentation, testing, validation, and production deployment) strongly preferred.

• Demonstrated experience supporting CMS audits (program, financial, or data validation), ensuring compliance, and managing highly regulated, deadline-driven environments such as annual plan year (1/1) go-live and command center activities strongly preferred.