Job DescriptionGeneral SummaryLeads complex negotiations with pharmacy benefit managers (PBMs), commercial payers, Medicare/Medicaid plans, and other third party pharmacy networks to secure fair reimbursement rates, transparent contract terms, and operationally feasible requirements for retail pharmacy, specialty pharmacy, infusion/ambulatory services, and pharmacy-based clinical programs. This role ensures contractual terms are accurately memorialized, compliant, and aligned with organizational strategy. Works independently and exercises substantial judgment while collaborating closely with pharmacy leadership, revenue cycle, finance, and population health teams.
ResponsibilitiesDuties and ResponsibilitiesRemote Work CapableEssential Functions:- Cultivates and maintains collaborative relationships with PBMs, health plans, and pharmacy network representatives, as well as internal pharmacy and revenue cycle teams.
- Leads all stages of pharmacy contract negotiations to ensure payment methodologies, dispensing fees, specialty reimbursement structures, DIR/GER terms, performance programs, and operational requirements are favorable and manageable.
- Manages an assigned portfolio of pharmacy contracts, including commercial prescription plans, Medicare Part D, Medicaid FFS/managed care programs, specialty pharmacy networks, and limited distribution drug network (LDD) opportunities.
- Analyzes the financial impact of proposed changes to reimbursement rates, MAC pricing, specialty tiers, performance metrics (e.g., adherence, gaps in care), audit provisions, credentialing, and payment timelines. Recommend adjustments or counterproposals as needed.
- In collaboration with pharmacy operations, finance, and compliance teams, ensures the organization can operationalize proposed contract changes and that final language accurately reflects negotiated terms.
- Maintains ongoing knowledge of PBM policies, network changes, CMS regulations, Medicaid pharmacy rules, specialty pharmacy accreditation requirements (URAC, ACHC), and industry contracting trends.
- Supports strategic system initiatives such as expanding specialty pharmacy services, pursuing limited distribution contracts, enabling white/brown/clear bagging, and optimizing retail pharmacy profitability.
- Monitors external market activity including PBM mergers, pharmacy network restructuring, reimbursement shifts, and state/federal policy changes impacting pharmacy reimbursement.
- Conducts research and prepares summaries, financial models, or reports related to pharmacy contract opportunities, risks, or strategic initiatives.
- Participates in internal committees, cross-functional teams, and annual education programs
- As needed, leads contracting efforts for pharmacy-related services (e.g., infusion, home delivery, DME, vaccines, clinical pharmacy initiatives).
- Independently manages priorities, negotiates timelines, and executes strategies with minimal supervision.
- Develops and oversees free-market drug access strategy.
Common Expectations:- Continuously assesses PBM and payer performance using audits, denial trends, reimbursement variance analysis, and performance program results.
- Supports continuous improvement within the pharmacy contracting and revenue cycle functions, recommending workflow enhancements or compliance improvements.
- Promotes teamwork, maintains professionalism, and supports organizational values and compliance standards.
- Maintains strict confidentiality regarding proprietary payer terms, pricing models, and pharmacy performance data.
Travel Requirements:- Estimated Amount: 10% - Regional travel (payer meetings, site visits, conferences)
QualificationsQualificationsMinimum Education:- Bachelors Degree In Pharmacy, Business, Finance, Accounting, Healthcare Administration, or related field. Required
- Masters Degree In Pharmacy Administration, Healthcare Administration, Business, or Payor/Provider Relations. Preferred
Work Experience:- 3 years Experience in pharmacy reimbursement, PBM operations, payer contracting, revenue cycle, or managed care pharmacy. Required
- 5 years Healthcare or pharmacy-related experience with direct involvement in PBM negotiations, pharmacy network operations, or specialty pharmacy contracting. Preferred
Knowledge, Skills, and Abilities:- Strong foundation in pharmacy reimbursement models, including: MAC pricing, AWP/WAC-based formulas, specialty drug pricing, DIR, GER, and performance-based reimbursement, and Medicare Part D and Medicaid pharmacy rules.
- Demonstrated skills in contract negotiations, financial/data analysis, project management, clear written and verbal communication, cross-functional team collaboration.
- Ability to work independently with complex contracts and sensitive payer relationships.
Benefits Offered:- Comprehensive health benefits
- Retirement savings plan
- Paid time off (PTO)
- Education assistance
- Financial education and support, including DailyPay
- Expanded Paid Parental Leave
For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)
