Manager, Payor Contracting & Network Development

AmeriPharma • Laguna Hills, CA

67d

About The Position

The Manager, Payor Contracting & Network Development is responsible for effectively managing strategic payer relationships and ensuring the successful negotiation and execution of contracts. This role serves as the primary liaison between AmeriPharma and its payers, focusing on establishing genuine, long-term, community-oriented partnerships. The manager will oversee optimization the development, negotiation, and compliance of payer contracts, while strategically assessing opportunities to improve financial performance, operational efficiency, and contract terms. The manager will ensure alignment with AmeriPharma's contracting standards while proactively identifying opportunities for relationship enhancement and contract optimization. A deep understanding of the specialty pharmacy, infusion therapy, and healthcare contracting landscape will be essential for success in this role.

Requirements

• Possess a deep understanding of both government programs (Medicare, Medicaid, TriCare) and commercial insurance models to inform payer contract terms.
• Ability to manage large volumes of complex contracts and projects while adhering to deadlines.
• Familiarity with claims adjudication and resolving non-compliance issues.
• Proficiency in word processing, spreadsheets, databases, and scheduling applications.
• Exceptional verbal communication skills for presenting complex topics clearly.
• Experience in synthesizing extensive data into concise summaries.
• Willingness to travel for negotiations and relationship-building activities.
• Bachelor’s Degree from an accredited institution or equivalent experience.
• 6+ years of experience in pharmacy contracting, pharmacy quality improvement, and/or pharmacy regulatory and payer compliance.
• 5+ years of professional experience in contract management or payer relations role, particularly within the healthcare space (specialty pharmacy and/or infusion therapy preferred).
• 3+ years of experience in writing, negotiating, and managing healthcare payer contracts.
• Proven experience in managing relationships and negotiating with health plans, PBMs, and other payer organizations.
• Skilled in developing and implementing performance improvement plans to enhance team efficiency and productivity.
• In-depth knowledge of pharmacy systems, workflows, and claims adjudication, with expertise in claim rejections and resolutions.
• Strong ability to manage customer expectations, resolve service-related issues, and foster positive relationships with clients.
• Proficient in Microsoft Office and communication platforms, with excellent verbal and written communication skills to facilitate clear information exchange.
• Demonstrated ability to interpret and apply industry guidelines, ensuring compliance, accuracy, and risk management.
• Expertise in fostering effective working relationships with payers, staff, and coworkers to enhance collaboration and team morale.
• Strong analytical, problem-solving, and decision-making skills, with a focus on achieving measurable outcomes.
• Focused on continuous quality improvement, actively reviewing and self-monitoring work for optimal results.
• Maintains confidentiality and works independently, demonstrating strong prioritization, time management, and delegation skills.
• Excellent interpersonal skills, with a track record of providing exceptional customer service and displaying keen organizational and attention-to-detail abilities.
• Ability to manage multiple tasks, delegate appropriately, and thrive in high-pressure environments, balancing workload across team members while ensuring quality delivery.

Responsibilities

• Develop sincere business relationships with payers, advocate for mutual interests and ensure the organization’s best interests are advanced.
• Engage strategically with payers to foster associations that advance AmeriPharma's community commitments.
• Lead the drafting, negotiation, and execution of payer contracts to ensure favorable and equitable terms for AmeriPharma.
• Monitor financial performance across payer contracts, ensuring compliance, maintaining fairness and consistency across all payer agreements, and identifying areas for improvement or adjustment.
• Oversee the payer relation team to implement and maintain payer contracts, ensuring cross-functional alignment and execution.
• Maintains organizational documents for educating appropriate subsidiaries on managed care contracts, including but not limited to contract databases and matrixes.
• Facilitates problem solving of escalated contractual, payer policy and operational issues through collaboration with managed care organizations and internal stakeholders.
• Collaborate with practices to develop effective payer contracting strategies that optimize network access and reimbursement.
• Guide practices through contract negotiations, providing support and expertise to achieve beneficial outcomes.
• Coordinate with various internal teams to assess the impacts of payer contracts on different divisions.
• Manage contract-related challenges and opportunities within assigned areas.
• Serve as a subject matter expert on pharmacy and medical contracting including but not limited to managed care; specialty, long-term care, and home infusion networks; Pharmacy Service Administration Organizations (PSAOs); Pharmacy Benefit Management (PBMs) and other relations.
• Ensure that contracts meet all regulatory requirements and incorporate effective strategies for dealing with payer-specific policies.
• Contribute to the strategic direction of payer contracting, ensuring contracts align with company goals and market demands.
• Stay informed on industry trends, regulatory changes, and payer-specific policies that could affect contract performance, and enhance awareness within the organization’s business models.
• Communicate policies and procedures clearly to payers, addressing inquiries confidently to ensure clarity and efficiency.
• Stay informed on healthcare market trends, proposing strategic adjustments to contracts to enhance AmeriPharma's market position.
• Analyze financial data to inform decision-making and contribute to leadership discussions.
• Ensure the accurate creation and documentation of all payer contracts, synthesizing complex information into clear and concise contract terms.
• Present complex contract terms and performance data in a professional and understandable manner to internal stakeholders.
• Oversee contract performance and compliance through detailed reporting and regular evaluations.
• Demonstrate knowledge of payment methodologies for commercial and government payers, aligning departmental processes accordingly.
• Lead and oversee payer contracting projects and coordination efforts within the organization for new contract opportunities, risks, and challenges, ensuring goals are met and the organization’s objectives are supported.
• Maintain a working knowledge of government healthcare plans and advocate for effective contracts within those frameworks.
• Understand commercial insurance models, incorporating insights into contract negotiations to ensure effectiveness.
• Represent AmeriPharma with confidence and enthusiasm, establishing credibility in all payer discussions.

Benefits

• Full benefits package including medical, dental, vision, life that fits your lifestyle and goals
• Great pay and general compensation structures
• Employee assistance program to assist with mental health, legal questions, financial counseling etc.
• Comprehensive PTO and sick leave options
• 401k program
• Plenty of opportunities for growth and advancement
• Company sponsored outings and team-building events
• Casual Fridays

What This Job Offers

• Job Type: Full-time
• Career Level: Manager