Director of PBM Contracting

Gifthealth Inc•Columbus, OH

just now•$150,000 - $200,000•Hybrid

About The Position

We are seeking a Director of PBM Contracting to join our Gifthealth team. Reporting to the Chief Legal Officer, this role serves as Gifthealth’s primary point of contact with all PBM partners and owns the full PBM contracting lifecycle, including negotiation of new and renewal agreements, reimbursement integrity and rate validation, compliance monitoring, and audit response. This position plays a key role in Payer Relations / Revenue Operations, ensuring alignment with organizational goals, operational excellence, and compliance standards. Pifthealth’s direct-to-patient model operates across multiple payer networks, and the terms we hold with our PBM partners directly shape our reimbursement rates, network eligibility, and compliance posture. The Director of PBM Contracting will build and lead a small team, work cross-functionally with pharmacy operations, finance, compliance, and technology, and ensure our PBM relationships are both commercially optimized and operationally sound.

Requirements

Bachelor’s degree or equivalent experience required; degree in healthcare administration, pharmacy, business, or a related field preferred.
8+ years of experience in PBM contracting, payer relations, pharmacy reimbursement, or pharmacy network management
Direct, hands-on experience negotiating PBM contracts
3+ years in a role with direct PBM negotiation accountability
Experience managing PBM audits through resolution
Experience working in or on behalf of a specialty pharmacy or mail order pharmacy operation.
Demonstrated familiarity with PBM contract economics including MAC pricing, AWP discount schedules, dispensing fees, network access terms, and audit provisions
Strong analytical skills and ability to work with adjudication data to identify reimbursement discrepancies and model contract financial impact
Track record of building and maintaining productive relationships with PBM contracting and network teams
Ability to translate payer obligations into operational priorities and hold cross-functional teams accountable.

Nice To Haves

Pharmacist (RPh or PharmD) licensure or Certified Pharmacy Technician (CPhT) with deep payer-side experience preferred.
Active participation in pharmacy association PBM forums or contracting continuing education preferred.
Experience in a DTP pharmacy model or with manufacturer-sponsored patient access programs
Prior experience at or contracting with major PBMs (ESI/Evernorth, CVS Caremark, OptumRx, Humana Pharmacy Solutions, Prime Therapeutics)
Familiarity with PSAO contracting structures
Working knowledge of CMS Part D pharmacy network regulations and state PBM legislation
Experience managing limited distribution network (LDN) contracts or specialty hub-to-pharmacy contracting arrangements.
Has sat across the table from PBM contracting teams and pushed back on terms that eroded pharmacy economics — not intimidated by PBM complexity, and uses it to Gifthealth’s advantage.
Maintains productive PBM relationships even when actively negotiating or disputing terms — professionally assertive, not adversarial.
Builds internal compliance monitoring systems that catch issues before they become audit findings — proactive, not reactive.
Distills complex PBM economics into clear summaries for executive audiences and is comfortable presenting reimbursement performance and contract negotiation strategy at the COO or C-suite level.
Builder mentality — excited to put in place the contracts, relationships, and compliance infrastructure that will define Gifthealth’s payer position for years ahead.

Responsibilities

Lead all PBM contract negotiations on behalf of Gifthealth, including new network agreements, renewals, amendments, and specialty contract structures. Develop negotiation strategies that optimize reimbursement rates, MAC appeals rights, network access terms, dispensing fee structures, and audit provisions. Own the full contract lifecycle from initial terms through execution and ongoing performance monitoring.
Serve as Gifthealth’s named point of contact with all PBM partners, including commercial, Medicare Part D, Medicaid managed care, and specialty PBMs. Build and maintain active working relationships with PBM contracting, network, and compliance teams. Represent Gifthealth professionally and authoritatively in every PBM interaction.
Own the process for validating that Gifthealth is receiving accurate reimbursements consistent with contracted terms across all PBM networks. Monitor adjudication data for rate anomalies, underpayments, and clawback patterns. Coordinate with pharmacy operations and finance to resolve discrepancies and recover owed reimbursements.
Ensure Gifthealth’s operations remain in continuous compliance with PBM network agreements, provider manuals, credentialing requirements, and performance standards. Monitor for contract amendments or policy updates from PBM partners and translate requirements into internal operational actions with appropriate lead time.
Serve as Gifthealth’s lead for PBM-initiated audits, coordinating evidence collection, preparing response documentation, communicating with PBM audit teams, and managing remediation. Work proactively to reduce audit risk through internal controls, documentation standards, and pre-audit readiness reviews.
Build and lead a team of PBM Contracting Specialists and Analysts. Assign and manage workload across the PBM portfolio, develop team expertise in contract analysis and payer relations, and create internal processes and tools that scale with Gifthealth’s growing network of PBM relationships.
Maintain an active continuing education posture across PBM contracting, reimbursement policy, pharmacy network legislation, and CMS guidance. Attend industry conferences, participate in pharmacy association forums, and leverage PBM partner relationships to stay ahead of changes that affect Gifthealth’s contract terms or compliance obligations.
Partner with pharmacy operations on network credentialing and compliance execution; with finance on reimbursement forecasting and per-dispense economics modeling; with technology on claims and adjudication data infrastructure; and with compliance and legal on contract review and regulatory interpretation.