Payor Contract Manager (Specialty Pharmacy)
About The Position
The Payor Contract Manager, Specialty Pharmacy manages the operational oversight, analysis, and administration of payor contracts supporting specialty pharmacy, home infusion, and ambulatory infusion services. The role ensures standardized, approved processes are used for contract implementation, maintenance, monitoring, and renewal to optimize reimbursement, ensure compliance, and support sustainable growth across commercial, Medicare, and Medicaid lines of business. The manager oversees the contract lifecycle and serves as a subject matter expert on contract terms and reimbursement. The position partners with finance, revenue cycle, IT, and pharmacy operations to resolve payment issues and translate contract requirements into accurate systems, billing, and claims processes. It also supports compliance, audits, internal education, payor escalations, access issues, and network participation inquiries.
Requirements
- Bachelor’s degree in Business, Healthcare Administration, Finance, or a related field, or an equivalent combination of education and experience.
- At least 5 years of experience in payor contracting, managed care, or contract administration within specialty pharmacy, infusion pharmacy, PBM, or health plan environments.
Responsibilities
- Manage the lifecycle of payor contracts, including review, interpretation, implementation, amendments, and renewals.
- Serve as a subject matter expert on contract terms, including reimbursement methodologies, fee schedules, carve-outs, drug-level pricing, site-of-care requirements, and network participation.
- Track contract expirations, renewals, and amendments to support uninterrupted access and compliance.
- Analyze reimbursement methodologies and identify reimbursement risks, underpayments, and revenue leakage.
- Partner with finance and revenue cycle to resolve reimbursement discrepancies and payment disputes and support forecasting, margin analysis, and payor profitability reporting.
- Translate contract terms into operational requirements for pharmacy systems, billing platforms, and claim adjudication logic.
- Coordinate with IT and pharmacy operations to ensure accurate pricing setup and payor-specific rules, including NDC requirements, J-codes, modifiers, and site-of-care billing logic.
- Support payor mapping associated with BIN/PCN, NCPDP, NPI, and taxonomy configurations.
- Ensure contracts comply with federal and state regulations, including CMS, Medicare Part B and D, Medicaid, 340B, and anti-kickback requirements.
- Maintain audit-ready documentation and support internal and external audits.
- Act as the primary contract resource for internal teams and provide contract education to support accurate billing and payor compliance.
- Support payor escalations, access issues, and network participation inquiries.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs, unless covered by a collective bargaining agreement
- Medical benefits
- Dental benefits
- Vision benefits
- Short- and long-term disability benefits
- 401(k) with company match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
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What This Job Offers
Job Type
Full-time
