Manager, Payor and PBM Relations

Clearway Health • Boston, MA

13d • $133,000 - $166,000 • Remote

About The Position

The Manager, Payor & PBM Relations, is responsible for leading efforts to secure and maintain access to specialty pharmacy networks on behalf of the hospital system’s specialty pharmacy. This role serves as the primary liaison between the health system and Pharmacy Benefit Managers (PBMs), focusing on network inclusion, credentialing, contract negotiation, and performance alignment to ensure access to specialty drugs and high-cost specialty therapies. Working cross-functionally with pharmacy leadership, legal, compliance, specialty operations, and finance teams, the Manager, Payor & PBM Relations navigates complex payor and PBM structures to advocate for the hospital’s clinical capabilities and operational readiness. This individual will lead access strategies that position the health system’s specialty pharmacy as a preferred partner for PBMs, driving both patient access and institutional revenue, as well as lead and oversee credentialing and recredentialing with the payors and PBMs.

Requirements

• A bachelor's degree in business administration, healthcare administration, or a related field is a requirement
• 5+ years of experience working in health insurance, healthcare systems, or PBM industry is required
• Possess strong verbal and written communication skills, suitable for interaction across all organizational levels and external contacts.
• Demonstrate advanced knowledge and experience in payor contracting and credentialing processes and methodologies.
• Display expertise in contract structures, terms, conditions, and risk mitigation, with a proven track record in executing and drafting business requirements and key performance indicators.
• Proficiently use Microsoft Word, Excel, PowerPoint, and Outlook.
• Exhibit the ability to organize and prioritize work effectively to achieve specific deliverables in a fast-paced environment with tight deadlines and competing priorities.
• Ability to influence, build and maintain effective relationships with critical external partners and payors which ultimately impact the business.
• Exhibit strong critical thinking and problem-solving abilities.
• Must possess a comprehensive understanding of the specialty pharmacy ecosystem, including the interplay between PBMs, payors, and hospital-based pharmacies.
• Demonstrate strong healthcare business acumen with an understanding of how payer and PBM access strategies influence downstream revenue, patient retention, and overall organizational growth.

Nice To Haves

• Master's degree preferred
• Pharmacy industry experience is highly desired
• Previous experience in a leadership capacity desired

Responsibilities

• Develop and execute payer engagement strategies and operational frameworks that enhance access, streamline payer interactions, and support revenue optimization.
• Collaborate with Clearway teams and health system partners to address payor, PSAOs and PBMs access and reimbursement challenges, tracking data and troubleshooting with internal and external teams.
• Recommend and educate internal and external partners on reimbursement opportunities and potential solutions.
• Build effective working relationships with national and local payors, PBMs, and PSAOs, ensuring preferred access to their networks through influence and negotiation.
• Review reimbursement rates and recommend improvements as necessary, keeping up to date with current best practices.
• Evaluate managed care trends, coverage patterns, and payer policies, providing information and education to Clearway and health system partners as needed.
• Attend corporate and site-based committee meetings, as well as other ad hoc meetings with health system personnel, to assess needs, communicate progress on specific projects, and develop relationships.
• Maintain a thorough knowledge of payor policies and industry developments related to specialty pharmaceuticals.
• Provide direct supervision of team member(s) including setting priorities, defining strategy, overseeing credentialing project execution, and ensuring alignment with organizational goals.
• Coach and develop team members through regular feedback, performance management, and mentorship while maintaining ownership of team deliverables, quality standards, and continuous improvement of credentialing processes.
• Manage access to and enrollment in specialty payor agreements by coordinating initial contracting, submission of credentialing applications, and ongoing recredentialing activities for health system partners. This includes gathering and validating required provider, facility, and organizational documentation; monitoring application status and timelines; responding to payor inquiries; and ensuring compliance with payor-specific requirements, regulatory standards, and internal policies. Maintain accurate records of enrollment status, renewal cycles, and contract effective dates to support uninterrupted reimbursement and network participation.

Benefits

• This information is being provided to promote pay transparency and equal employment opportunities at Clearway Health.
• The current annual compensation range for this position is $133,000 - $166,000.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 1-10 employees