Director, Pharmacy Benefit Manager
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Job Description
Director leading PBM contracting, payer relations, and growth for CSI Pharmacy’s national specialty pharmacy services. Managing agreements, reimbursement strategy, credentialing, and client implementation.
Responsibilities:
- Lead the growth and strategic development of the Company’s PBM business, including client acquisition, implementation, retention, and expansion
- Lead negotiation, implementation, and ongoing administration of managed care across the assigned region
- Develop and maintain processes for disseminating contract terms, reimbursement methodologies, operational requirements, and payer updates
- Manage the full contract lifecycle, including evaluation, negotiation, approval, implementation, monitoring, renewal, amendment, and termination
- Analyze contract performance and reimbursement trends to identify revenue optimization and operational improvement opportunities
- Serve as primary point of contact for payer relations and contract performance management
- Collaborate with leadership, revenue cycle, operations, billing, pharmacy, compliance, and credentialing teams
- Develop relationships with medical and pharmacy benefit plans to secure competitive reimbursement rates and favorable contract language
- Oversee payer credentialing and recredentialing activities
- Assist operational teams with prior authorizations, eligibility verification, referrals, enrollment, billing concerns, and payer education
- Monitor payer compliance and address reimbursement, operational, and performance issues
- Identify market opportunities and support strategic payer engagement and business development
- Communicate payer trends, reimbursement changes, regulatory developments, and network opportunities to leadership
- Represent the company with payers, clients, providers, and industry stakeholders
- Maintain effective relationships across departments
- Adhere to company policies, compliance requirements, regulatory standards, and applicable laws
- Perform other assigned duties
Requirements:
- Bachelor’s Degree preferred or equivalent experience
- Minimum of five (5) years of progressive experience in PBM operations, PBM sales, pharmacy contracting, managed care contracting, or specialty pharmacy leadership
- Demonstrated success negotiating PBM, specialty pharmacy, and managed care agreements
- Preferred experience managing, analyzing, and reporting denials and appeals
- Knowledge of Medicare, Medicaid, commercial payer reimbursement methodologies, pharmacy benefit design, and provider payment structures
- Ability 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 change direction
- Successful completion of a drug screen prior to employment
- Ability to work Monday–Friday, 8:00am–4:30pm CST or EST, with some flexibility
- Ideal residence in a CST or EST state
Benefits:
- Remote work arrangement
- Schedule flexibility
- 25–30% travel for conferences, including local travel as needed
- Reasonable accommodations for individuals with disabilities
- Equal Opportunity Employer
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