Director, Health Care Strategy & Plan Economics

Director Health Care Strategy & Plan Economics

Location: Durham, NC — Hybrid

ABOUT US

Victra is Verizon’s largest premium retailer in the United States. We thrive on collaboration, innovation, and performance. Our mission is to “Connect technology to life in a trustworthy, fun, and profitable way”. We work closely with Verizon and our brand partners to deliver exceptional product offerings, promotions, and campaigns that drive in-store traffic and revenue.

JOB DESCRIPTION

Victra is self-insured for medical benefits, administering claims through a third-party administrator (TPA) and pharmacy benefits through a pharmacy benefit manager (PBM), with stop-loss reinsurance covering catastrophic claims. This role owns the financial performance of that program end to end — the plan's single largest controllable SG&A line outside of labor. The successful candidate will function as an internal actuary, contract negotiator, and plan-design strategist rolled into one, partnering with Finance and HR/Total Rewards to re-underwrite how Victra buys and manages health care. This is a self-funding role expected to identify, execute, and validate savings that are a multiple of its own fully-loaded cost within the first 12–18 months, and to build a durable cost-management discipline thereafter.

Initially an individual contributor, this role may scale to lead 1–2 analysts focused on benefits analytics and vendor management as the program matures.

KEY RESPONSIBILITIES

TPA & Claims Economics

• Own the TPA relationship: performance guarantees, administrative fee benchmarking, claims-payment accuracy audits, and periodic competitive RFPs (typically every 3–5 years) to keep fees and service levels market-tested.
• Commission and act on independent claims audits; recover overpayments and correct systemic adjudication errors.
• Drive dependent eligibility audits, coordination-of-benefits recovery, and subrogation/third-party liability recovery to eliminate ineligible and duplicate spend.

PBM & Pharmacy Spend

• Negotiate and audit PBM contracts for full pricing transparency: pass-through vs. spread pricing, 100% rebate pass-through, guaranteed effective rates, and audit rights — aligned with 2026 PBM reform and DOL fee-disclosure rules that raise ERISA fiduciary expectations for plan sponsors.
• Manage formulary strategy, specialty/biosimilar utilization, and site-of-care steerage for infusions and high-cost specialty drugs.
• Build and continuously refine Victra's GLP-1 (weight-loss/diabetes) coverage strategy — eligibility criteria, utilization management, lifestyle-program pairing, and vendor point-solution evaluation — given GLP-1s are now one of the fastest-growing cost drivers for self-insured plans nationally.
• Run PBM RFPs on a disciplined cadence (typically every 2–3 years) using independent pricing benchmarks.

Plan Design & Network Strategy

• Redesign benefit tiers, networks, and steerage incentives (reference-based pricing, narrow/tiered networks, centers of excellence for high-cost procedures, bundled-payment arrangements) to shift utilization toward high-value care without shifting unreasonable cost to associates.
• Evaluate and rationalize point solutions (MSK, virtual care, fertility, diabetes management, second-opinion services) for real ROI versus fee-stacking.
• Partner with HR/Total Rewards on plan design changes that balance cost, competitiveness in a large hourly-retail workforce, and ACA compliance (eligibility measurement periods, affordability).

Risk, Stop-Loss & Financial Stewardship

• Own the annual stop-loss/reinsurance placement — specific and aggregate attachment points, captive or level-funding alternatives — in partnership with Treasury and outside brokers/actuaries.
• Build and maintain a high-cost claimant / large-case management program in coordination with the TPA's clinical team to reduce catastrophic claim severity.
• Develop the plan's annual financial forecast, IBNR estimates, and trend assumptions in partnership with FP&A; report plan performance, savings realized, and risk exposure to the CFO and executive team.

Governance, Data & Compliance

• Serve as (or directly support) the plan's ERISA fiduciary function: ensure documented, defensible processes for evaluating vendor fees and compensation, consistent with heightened PBM/TPA fee-disclosure and fiduciary-duty scrutiny under CAA and 2026 PBM reform.
• Build claims data and analytics capability (independent of TPA/PBM-provided reporting) to identify cost drivers, benchmark against peer self-insured employers, and validate vendor-reported savings.
• Maintain compliance with the No Surprises Act, price transparency, mental health parity (MHPAEA), and RxDC reporting requirements.

Success Metrics

• Net medical/Rx trend held below national benchmark (typically 6–9% gross trend for self-insured plans) and, over time, below Victra's historical trend.
• Documented, verifiable savings of 3–5x the role's fully-loaded cost within the first 12–18 months, sustained annually thereafter.
• Successful RFP/renegotiation outcomes for TPA and/or PBM contracts with improved transparency terms and audit rights.
• Reduced per-employee-per-year (PEPY) cost trend and stop-loss loss ratio improvement.
• Clean SOX/ERISA fiduciary governance record with no unresolved audit findings.

WHAT WE ARE LOOKING FOR

Required Qualifications

• 10+ years in health plan strategy, benefits consulting, PBM/TPA account management, or health plan actuarial/underwriting roles, including direct experience with a self-insured (self-funded) employer plan.
• Demonstrated history negotiating PBM and/or TPA contracts and quantifying resulting savings.
• Deep working knowledge of stop-loss/reinsurance structures, ERISA fiduciary obligations, and current PBM transparency/compensation-disclosure requirements.
• Strong financial and analytical skills — comfortable building trend models, IBNR estimates, and ROI cases, and defending them to a CFO and Finance audience.
• Bachelor's degree in finance, health administration, actuarial science, or related field.

Preferred Qualifications

• Experience in multi-site retail, restaurant, or other large hourly-workforce environments.
• Professional designation such as CEBS, ASA/FSA, or health care management consulting background (e.g., Mercer, Aon, WTW, Milliman).
• Direct experience running competitive TPA or PBM RFPs from specification through implementation.
• Familiarity with reference-based pricing, direct-to-employer provider contracting, or captive stop-loss arrangements.

TRAVEL REQUIREMENTS

• Occasional travel to visit TPA/PBM finalist sites and attend industry forums.

WHY JOIN US

• Paid training and career development opportunities.
• Comprehensive health, dental, and vision insurance.
• 401k retirement plan.
• Tuition reimbursement.
• Employee discounts on Verizon services.
• Referral bonuses
• Career pathing opportunities.

EQUAL OPPORTUNITY EMPLOYER

We're proud to be an equal opportunity employer - and celebrate our employees' differences, regardless of race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, or Veteran status. Different makes us better.