Director, Pharmacy Benefit Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Drive the growth and strategic advancement of the Company’s PBM business, encompassing client acquisition, implementation, retention, and expansion.

• Direct negotiations, implementation, and continuous management of managed care within the designated region.

• Establish and uphold processes for distributing contract terms, reimbursement models, operational requirements, and payer updates.

• Oversee the entire contract lifecycle, including evaluation, negotiation, approval, implementation, monitoring, renewal, amendment, and termination.

• Evaluate contract performance and reimbursement trends to uncover opportunities for revenue enhancement and operational improvements.

• Act as the primary liaison for payer relations and contract performance oversight.

• Collaborate with leadership, revenue cycle, operations, billing, pharmacy, compliance, and credentialing teams.

• Build relationships with medical and pharmacy benefit plans to obtain competitive reimbursement rates and advantageous contract terms.

• Supervise payer credentialing and recredentialing processes.

• Support operational teams with prior authorizations, eligibility verification, referrals, enrollment, billing inquiries, and payer education.

• Track payer compliance and resolve reimbursement, operational, and performance challenges.

• Identify market opportunities and assist in strategic payer engagement and business development initiatives.

• Relay payer trends, reimbursement alterations, regulatory changes, and network opportunities to leadership.

• Represent the company in interactions with payers, clients, providers, and industry stakeholders.

• Foster effective relationships across various departments.

• Comply with company policies, regulatory requirements, legal standards, and applicable laws.

• Execute other assigned responsibilities.

⛳️ Requirements

• Bachelor’s Degree preferred or equivalent experience.

• At least five (5) years of progressive experience in PBM operations, PBM sales, pharmacy contracting, managed care contracting, or specialty pharmacy leadership.

• Proven success in negotiating PBM, specialty pharmacy, and managed care agreements.

• Preferred experience in managing, analyzing, and reporting on denials and appeals.

• Familiarity with Medicare, Medicaid, commercial payer reimbursement methods, pharmacy benefit design, and provider payment structures.

• Capability to establish and maintain a system for reviewing and assessing changes in Federal and/or State managed care contract regulations.

• Ability to multitask and frequently adapt to changing directions.

• Successful completion of a drug screening prior to employment.

• Availability to work Monday–Friday, 8:00 AM–4:30 PM CST or EST, with some flexibility.

• Preferred residence in a CST or EST state.

🏝️ Benefits

• Remote work arrangement.

• Schedule flexibility.

• 25–30% travel for conferences, including local travel as necessary.

• Reasonable accommodations for individuals with disabilities.

• Equal Opportunity Employer.