Pharmacy Provider Relations Manager

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

📋 Description

• Oversee relationships with pharmacies within Ohio’s network and facilitate pharmacy outreach, contract execution, and ongoing network upkeep.

• Act as an intermediary between pharmacies and internal Gainwell teams, including finance, claims, operations, compliance, and client-facing partners.

• Assess pharmacy network adequacy, access-to-care requirements, and address network-to-pharmacy concerns, including member access and travel factors.

• Ensure accurate provider directory information, pharmacy network data, policies, procedures, and out-of-network processes are maintained.

• Assist with Ohio claims-related communications by guaranteeing that pharmacy network information is precise, timely, and disseminated to pharmacy staff.

• Generate operational, KPI, client, monthly, quarterly, and pharmacy network management reports.

• Aid in third-party audits, including those conducted by CMS, ISCA, and the Ohio Department of Medicaid.

• Identify potential risks, address inquiries, escalate network issues, and support process enhancements, new service requirements, and RFP-related tasks.

• Regularly communicate with pharmacies, internal Gainwell partners, and stakeholders related to Ohio Medicaid.

• Collaborate with finance, claims, operations, compliance, and client-facing teams to enhance network performance.

⛳️ Requirements

• A minimum of 5 years of experience in PBM, pharmacy operations, drug claims processing, pharmacy network management, or contracting.

• At least 2 years of leadership or supervisory experience.

• Preferred experience in pharmacy network management within Ohio Medicaid or PBM settings.

• In-depth knowledge of pharmacy claims adjudication, Medicaid programs, PBM operations, and pharmacy network maintenance.

• Proven experience in client communications, client-facing interactions, relationship management, and cross-functional collaboration.

• Familiarity with operational reporting, KPIs, audits, process enhancement, data analysis, and proficiency in Excel.

• Capable of working with urgency, handling multiple priorities, communicating clearly in a fast-paced, time-sensitive environment, and supporting Eastern Time business hours.

• Must be able to work during Eastern Time hours.

🏝️ Benefits

• Flexible work arrangements.

• Opportunities for learning and career advancement.

• Generous and adaptable vacation policy.

• 401(k) employer matching.

• Comprehensive health insurance options.

• Educational support.

• Leadership and technical development academies.