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.
Proven ability to interpret complex health plan benefit requirements, translate into accurate adjudication logic, and manage high-priority production issues with speed, precision, and accountability in time-sensitive environments strongly preferred.
Strong cross-functional leadership experience partnering with product, clinical, compliance, and external vendor teams, with the ability to influence outcomes without direct authority and operate effectively in a highly matrixed organization strongly preferred.
Exceptional strategic thinking, attention to detail, and communication skills, including experience engaging senior leadership, combined with healthcare payer experience (Medicare pharmacy operations highly preferred), advanced degree, and/or Six Sigma Black Belt certification preferred.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/) .
