Director Pharmacy Benefit Manager
About The Position
The Director Pharmacy Benefit Manager is responsible for the evaluation, negotiation, implementation, credentialing, and ongoing management of managed care and Pharmacy Benefit Manager (PBM) agreements with new and existing health plans, payers, and managed care organizations. This role is focused on securing financially advantageous and operationally sustainable contract terms while strengthening strategic relationships across the healthcare ecosystem. In addition, the Director Pharmacy Benefit Manager will provide leadership in the sales, account management, implementation, and operational oversight of PBM services for large national clients, including health plans, employers, insurers, third-party administrators, and government entities. The ideal candidate possesses a strong understanding of specialty pharmacy reimbursement, payer contracting, Medicare and Medicaid programs, and healthcare revenue cycle operations.
Requirements
- Bachelor’s Degree preferred or equivalent experience
- Minimum of five (5) years of progressive experience in PBM operations, PBM sales, pharmacy contracting, managed care contracting, or specialty pharmacy leadership.
- Demonstrated success negotiating PBM, specialty pharmacy, and managed care agreements.
- Establish and maintain a system of reviewing and assessing changes in the Federal and or State regulations regarding Managed Care contracts
- Provide the highest level of professionalism, responsiveness, and communication in order to build and maintain the maximum customer base possible
- Must possess the ability to multi-task and frequently change direction.
Nice To Haves
- Preferred experience in managing, analyzing, and reporting denials and appeals.
Responsibilities
- Lead the growth and strategic development of the Company's PBM business, including client acquisition, implementation, retention, and expansion initiatives.
- Lead the negotiation, implementation, and ongoing administration of managed care across the assigned region.
- Develop and maintain processes to ensure timely dissemination of contract terms, reimbursement methodologies, operational requirements, and payer updates to key stakeholders.
- Manage all phases of the contract lifecycle, including evaluation, negotiation, approval, implementation, monitoring, renewal, amendment, and termination activities.
- Analyze contract performance and reimbursement trends to identify opportunities for revenue optimization and operational improvement.
- Maintain a comprehensive understanding of Medicare, Medicaid, commercial payer reimbursement methodologies, pharmacy benefit design, and provider payment structures.
- Serve as the primary point of contact for payer relations and contract performance management.
- Collaborate with leadership, revenue cycle, operations, billing, pharmacy, compliance, and credentialing teams to ensure successful contract implementation and ongoing compliance.
- Develop and strengthen relationships with medical and pharmacy benefit plans to secure competitive reimbursement rates and favorable contract language.
- Oversee payer credentialing and recredentialing activities to ensure uninterrupted network participation.
- Assist operational teams with payer-related issues, including prior authorizations, eligibility verification, referrals, enrollment requirements, billing concerns, and payer education initiatives.
- Monitor payer compliance with contract terms and address reimbursement, operational, or performance issues as they arise.
- Identify market opportunities and support growth initiatives through strategic payer engagement and business development activities.
- Regularly communicate payer trends, reimbursement changes, regulatory developments, and network opportunities to leadership.
- Represent the company professionally in all interactions with payers, clients, providers, and industry stakeholders.
- Maintain effective working relationships with colleagues across all departments.
- Adhere to all company policies, compliance requirements, regulatory standards, and applicable federal and state laws.
- Perform other duties and responsibilities as assigned.
Benefits
- Employee Type: Employee
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What This Job Offers
Job Type
Full-time
Career Level
Director
Education Level
Associate degree
