Specialist, Contract Operations

Nufactor • Temecula, CA

3d • Onsite

About The Position

The Specialist, Contract Operations is responsible for the operational oversight, implementation, governance, and lifecycle management of payer contract data, reimbursement methodologies, pricing structures, and system configuration requirements within specialty pharmacy systems. This role exercises independent judgment and operational discretion in translating payer contract requirements into scalable operational and system-based solutions that support reimbursement accuracy, claims adjudication integrity, and downstream financial realization. The Specialist serves as a key operational resource supporting cross-functional contract implementation, pricing governance, reimbursement configuration, operational issue resolution, and data integrity management across all payer types. Operating in partnership with Managed Markets, Reimbursement, Operations, Quality Assurance, Finance, and IT, this role is responsible for evaluating operational impacts, identifying configuration risks, resolving reimbursement-impacting discrepancies, and supporting operational decision-making associated with contract operationalization and payer implementation activities. The Specialist directly contributes to operational scalability, reimbursement integrity, governance compliance, and continuous process optimization initiatives supporting the organization’s long-term growth strategy.

Requirements

• Bachelor’s degree in Business Administration, Healthcare Administration, Finance, Data Analytics, or a related field
• Equivalent professional experience may be considered in lieu of degree requirements
• Minimum four (4) to six (6) years of progressively responsible experience in healthcare contract operations, reimbursement operations, payer configuration, pricing governance, specialty pharmacy operations, managed care operations, or related operational environments
• Experience exercising independent judgment in operational implementation, reimbursement support, pricing governance, or contract operationalization activities
• Experience supporting cross-functional operational implementation, issue resolution, and workflow optimization initiatives
• Strong understanding of payer structures, reimbursement methodologies, pricing logic, and operational configuration principles
• Knowledge of healthcare reimbursement processes, claims adjudication workflows, and specialty pharmacy operations
• Understanding of operational governance, data integrity controls, and audit readiness standards
• Knowledge of structured data management, operational workflows, and system configuration methodologies
• Strong analytical and operational problem-solving capabilities
• Ability to exercise independent judgment and operational discretion within established governance frameworks
• Ability to evaluate reimbursement impacts, operational dependencies, and configuration risks
• Strong business acumen and operational decision-making capabilities
• Exceptional attention to detail and commitment to operational accuracy
• Strong written and verbal communication skills
• Ability to independently prioritize and manage multiple operational activities in a fast-paced environment
• Advanced proficiency in Microsoft Excel and operational reporting tools
• Ability to collaborate effectively across cross-functional operational and leadership teams

Nice To Haves

• Bachelor’s degree in a healthcare, finance, business, analytics, or operational discipline
• Experience within specialty pharmacy, healthcare reimbursement, managed care, or payer operations environments
• Experience supporting payer implementation, pricing governance, reimbursement analysis, or operational configuration activities
• Experience working within audit, compliance, governance, or operational control-focused environments
• Experience with specialty pharmacy systems, ERP platforms, payer systems, or reimbursement platforms
• Exposure to automation initiatives, workflow optimization, or operational analytics
• Experience supporting operational governance, audit preparation, or reimbursement controls

Responsibilities

• Lead operational implementation and lifecycle management activities associated with payer contract configurations, reimbursement methodologies, and pricing structures within specialty pharmacy systems
• Interpret payer contract requirements and determine appropriate operational and system configuration approaches to support reimbursement accuracy and downstream claims processing integrity
• Maintain payer mappings, reimbursement structures, pricing logic, and configuration elements required to support accurate claims adjudication and operational execution
• Review, analyze, and resolve complex operational discrepancies, configuration issues, and reimbursement-impacting data integrity concerns
• Recommend corrective actions and operational improvements to mitigate reimbursement risk and strengthen configuration accuracy
• Oversee recurring pricing update processes including monthly, quarterly, and ad hoc pricing maintenance activities across methodologies including AWP, ASP, WAC, NADAC, and payer-specific fee schedules
• Analyze pricing methodologies, reimbursement structures, and operational impacts associated with payer pricing configurations
• Retrieve, validate, interpret, and apply pricing data from external reimbursement and pricing sources including Redbook, RJ Health, Medicaid, and Medicare
• Ensure pricing updates are accurately implemented across impacted systems and operational workflows
• Lead operational implementation activities associated with executed payer agreements and reimbursement structures
• Partner cross-functionally with Managed Markets, Reimbursement, Operations, Intake, Authorizations, Quality Assurance, Finance, and IT to support operational readiness and implementation alignment
• Provide operational guidance and recommendations regarding payer configuration requirements, reimbursement structures, implementation dependencies, and system readiness
• Independently prioritize implementation activities based on operational urgency, reimbursement impact, and downstream business dependencies
• Support operational decision-making associated with payer onboarding, reimbursement implementation strategy, and operational scalability initiatives
• Maintain audit-ready documentation supporting payer configurations, pricing updates, reimbursement structures, and operational changes
• Ensure all updates and configuration activities remain traceable, version-controlled, and aligned to governance and compliance standards
• Evaluate operational workflows, governance controls, and reimbursement processing dependencies to identify opportunities for operational improvement and risk reduction
• Identify operational risks, reimbursement-impacting discrepancies, and data integrity concerns requiring escalation or corrective action
• Support development and enhancement of governance controls, operational procedures, and scalable workflow standards
• Evaluate operational processes and recommend workflow enhancements, automation opportunities, and system optimization initiatives
• Participate in operational planning and process improvement initiatives supporting scalability, reimbursement integrity, and operational efficiency
• Support implementation of standardized operational frameworks and repeatable control structures across payer and reimbursement operations
• Contribute to cross-functional initiatives focused on improving operational accuracy, reducing manual intervention, and strengthening reimbursement outcomes
• Adheres specifically to all company policies and procedures, Federal and State regulations, and laws.
• Display dedication to position responsibilities and achieve assigned goals and objectives.
• Always represent the Company in a professional manner and appearance.
• Understand and internalize the Company’s purpose, display loyalty to the Company and its organizational values.
• Display enthusiasm and dedication to learning how to be more effective on the job and share knowledge with others.
• Work effectively with co-workers, internal and external customers and others by sharing ideas in a constructive and positive manner; listen to and objectively consider ideas and suggestions from others; keep commitments; keep others informed of work progress, timetables, and issues; address problems and issues constructively to find mutually acceptable and practical business solutions; address others by name, title, or other respectful identifier, and respect the diversity of our work force in actions, words, and deeds.
• Comply with the policies and procedures stated in the Injury and Illness Prevention Program by always working in a safe manner and immediately reporting any injury, safety hazard, or program violation.
• Ensure conduct is consistent with all Compliance Program Policies and procedures when engaging in any activity on behalf of the company. Immediately report any concerns or violations.
• Other duties as assigned.

Benefits

• Vision, hearing, speech, movements requiring the use of wrists, hands and/or fingers.
• Ability to view a computer screen for prolonged periods and the ability to sit for extended periods.
• Ability to work the hours and days required to complete the essential functions of the position, as scheduled.
• Ability to lift and maneuver items of at least 50 lbs.
• Ability to travel occasionally.

What This Job Offers

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