Network Specialist

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

📋 Description

• Conduct research and resolve issues related to payments, reimbursements, claims exceptions, and network participation.

• Analyze claims, reimbursement, and operational data to detect trends, anomalies, and intricate operational challenges.

• Collaborate with member pharmacies, PBMs, payers, Net-Rx or similar platform partners, and internal teams to investigate and address reimbursement issues.

• Appropriately escalate issues and communicate findings, suggested next steps, and resolutions.

• Oversee assigned strategic member accounts, providing responsive and proactive support alongside Account Executives and internal stakeholders.

• Engage in member business reviews, regional meetings, and discussions with members; prepare and present updates, performance metrics, and value of the Network.

• Cultivate and sustain relationships with member pharmacies and key stakeholders to enhance satisfaction and retention.

• Offer expertise in payer contracts, reimbursement methodologies, Medicare Part D, Medicaid, managed care, network participation, claims processing, enrollment, and eligibility.

• Coordinate the retrieval and review of payer contracts, compliance, credentialing, enrollment, information changes, and escalated member issues.

• Manage enrollment activities for pharmacy LTC Networks, including demographic changes, payer information, credentialing, and compliance obligations.

• Identify opportunities for member pharmacies to utilize additional MHA Network Services.

• Create and maintain monthly reports, dashboards, reporting summaries, and operational analyses.

• Assess claims and operational data for accuracy and consistency, and coordinate follow-up on discrepancies.

• Prepare and disseminate network communications, FAQs, training materials, process documentation, and resources for members.

• Utilize approved AI, automation, reporting, and productivity tools to enhance efficiency, analysis, reporting, and communication.

• Identify operational inefficiencies, propose enhancements, and support the implementation of solutions.

• Collaborate with Sales, Account Management, Operations, Finance, and other business partners.

• Handle multiple member requests, projects, priorities, and deadlines.

• Stay informed about Network activities, member needs, payer developments, and industry trends.

• Willingness to travel 25-50% of the time.

⛳️ Requirements

• Familiarity with pharmacy reimbursement methodologies, payer networks, Medicare Part D, Medicaid, managed care, enrollment, eligibility, claims processing, and payer or pharmacy contracting.

• Knowledge of pharmacy network operations, contracting, and member support processes.

• Strong analytical and reporting capabilities, including the ability to identify trends, discrepancies, anomalies, and operational issues within claims and operational data.

• Proficient in Microsoft Office products, particularly with strong Excel capabilities.

• Capacity to interpret data and convert findings into clear, actionable recommendations.

• Ability to build robust working relationships with member pharmacies, Account Executives, PBMs, payers, and internal business partners.

• Strong customer service focus with a proactive, responsive approach to member needs and issue resolution.

• Excellent verbal, written, presentation, and customer service skills.

• Capability to convey complex information clearly to both technical and non-technical audiences.

• Proven ability to collaborate effectively across departments and work independently.

• Strong organizational and project management abilities, attention to detail, and skill in managing multiple priorities and deadlines.

• At least one year of experience in PBM account management, pharmacy network contracting, claims, reimbursement, managed care, or equivalent client-facing healthcare experience.

• Willingness to travel 25-50% of the time.

• Bachelor’s degree preferred.

• Experience in long-term care pharmacy preferred.

• Familiarity with reporting tools and databases preferred.

• Experience with Net-Rx or a comparable pharmacy, healthcare, claims, or reimbursement platform preferred.

• Background in developing reports, member-facing communications, FAQs, training materials, process documentation, and operational resources preferred.

• Experience using Salesforce or a similar customer relationship management platform preferred.

🏝️ Benefits

• Comprehensive medical, dental, and vision plans with FSA/HSA options.

• Fitness reimbursement.

• Access to an Employee Assistance Program.

• Paid time off, holidays, personal days, paid parental leave, plus your Birthday as a day off.

• Life insurance.

• Short-term and long-term disability insurance.

• 401K match.

• Employee Stock Purchase Plan.

• Voluntary financial and legal benefits through benefits providers.

• E-learning programs.

• Tuition reimbursement.

• Ongoing team trainings.

• Paid volunteer time-off.

• Donation matching.

• Remote work environment.