PBM Operations Associate

Our pharmacy benefit management (PBM) offering represents an important growth area for Rightway. Helping clients better manage pharmacy spend to make drugs more affordable for their employees and dependents is critical to their business sustainability. Rightway is responsible for designing, building, and operating a new-to-the-world PBM model base on our core tenets: fairness & transparency, unlocking the supply chain, supporting the physician-patient relationship, and utilizing navigation to empower consumers The PBM Operations Analyst is a member of the Rightway Operations team reporting to the Director, Claims & Data Operations. This role will be responsible for the configuration, testing and maintenance of benefits, and related claims adjudication rules within the claim platform along with ongoing management of data operations.

Review client benefit design documentation for completeness and accuracy, flagging open items and partnering with implementation and client success to resolve gaps prior to configuration.

Configure client benefit designs in the claims adjudication platform, including plan parameters, copay structures, inclusions and exclusions, and utilization management edits, for both new client implementations and mid-year plan changes.

Develop and execute test claim scenarios to validate benefit setup prior to go-live, and perform ongoing monitoring and regression testing to confirm accuracy after changes. Research, document, and correct identified defects through to resolution.

Research and resolve inquiries related to claims adjudication and benefit configuration, partnering with client success to communicate findings and remediation steps.

Work cross-functionally with product, client success, implementation, and formulary teams to ensure benefits are built and operating according to signed client requirements.

Maintain complete, audit-ready documentation of benefit setup, testing evidence, and internal controls in support of audit and internal quality standards.

Track work across implementation and plan change trackers, keeping status, ownership, and deadlines current so cross-functional partners have real-time visibility.

Bachelor’s degree preferred; relevant experience considered for exceptional candidates.

1-3 years of PBM experience in claims adjudication, benefit configuration, or testing/QA.

Pharmacy Technician certification or related pharmacy experience highly desirable.

Strong attention to detail with the ability to trace a claim outcome back to its configuration driver.

Comfortable navigating ambiguity; able to work from incomplete requirements, ask the right questions, and exercise sound judgment when documentation doesn’t cover every scenario.

Comfortable working in structured tools (Excel, Smartsheet, claims platforms) and managing multiple client deliverables against firm deadlines.

Clear written communicator who documents decisions and keeps stakeholders informed without being prompted.

In response to ongoing and industry-wide fraudulent recruitment activities (i.e., job scams), Rightway wants to inform potential candidates that we will only contact them from the @ rightwayhealthcare.com email domain. We will never ask for bank details or deposits of any kind as a condition of employment.

Rightway is on a mission to harmonize healthcare for everyone, everywhere. Our products guide patients to the best care and medications by inserting clinicians and pharmacists into a patient’s care journey through a modern, mobile app. Rightway is a front door to healthcare, giving patients the tools they need along with on-demand access to Rightway health guides, human experts that answer their questions and manage the frustrating parts of healthcare for them.

Since its founding in 2017, Rightway has raised over $200mm from investors including Khosla Ventures, Thrive Capital, and Tiger Global. We’re headquartered in New York City, with satellite offices in Denver and Dallas. Our clients rely on us to transform the healthcare experience, improve outcomes for their teams, and decrease their healthcare costs.

We’re seeking those with passion for healthcare and relentless devotion to our goal. We need team members that embody our core values:

1) We are human, first Our humanity binds us together. We bring the same empathetic approach to every individual we engage with, whether it be our members, our clients, or each other. We are all worthy of respect and understanding and we engage in our interactions with care and intention. We honor our stories. We listen to—and hear—each other, we celebrate our differences and similarities, we are present for each other, and we strive for mutual understanding.

2) We redefine what is possible We always look beyond the obstacles in front of us to imagine new solutions. We approach our work with inspiration from other industries, other leaders, and other challenges. We use ingenuity and resourcefulness when faced with tough problems.

3) We debate then commit We believe that a spirit of open discourse is part of a healthy culture. We understand and appreciate different perspectives and we challenge our assumptions. When working toward a decision or a new solution, we actively listen to one another, approach it with a “yes, and” mentality, and assume positive intent. Once a decision is made, we align and champion it as one team.

4) We cultivate grit Changing healthcare doesn’t happen overnight. We reflect and learn from challenges and approach the future with a determination to strive for better. In the face of daunting situations, we value persistence. We embrace failure as a stepping stone to future success. On this journey, we seek to act with guts, resilience, initiative, and tenacity.

5) We seek to delight Healthcare is complicated and personal. We work tirelessly to meet the goals of our clients while also delivering the best experience to our members. We recognize that no matter the role or team, we each play a crucial part in our members’ care and take that responsibility seriously. When faced with an obstacle, we are kind, respectful, and solution-oriented in our approach. We hold ourselves accountable to our clients and our members’ success.

Rightway is proud to be an Equal Opportunity Employer that believes in the strength of diverse thought, beliefs, backgrounds, and education. We foster an inclusive culture where differences are celebrated to drive the best business decisions possible. We do not discriminate on any basis protected by applicable law. All employment decisions are based on merit, qualifications, need, and performance.