Payor Contract Manager (Specialty Pharmacy)

Payor Contract Manager (Specialty Pharmacy)

Hybrid: This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

The Payor Contract Manager, Specialty Pharmacy manages the operational management, analysis, and administration of payor contracts supporting specialty pharmacy, home infusion, and ambulatory infusion services and ensures that standardized and approved processes are utilized for contract implementation, maintenance, monitoring, and renewal activities to optimize reimbursement, ensure compliance, and support sustainable growth across commercial, Medicare, and Medicaid lines of business.

How you will make an impact:

• Manages the lifecycle of payor contracts including review, interpretation, implementation, amendments, and renewals.
• Serves as subject matter expert on contract terms including reimbursement methodologies, fee schedules, carve-outs, drug-level pricing, site-of-care requirements, and network participation.
• Tracks contract expirations, renewals, and amendments to ensure uninterrupted access and compliance.
• Analyzes reimbursement methodologies (AWP, WAC, ASP, MAC, per diem, case rates, nursing fees, supplies, admin fees) and identifies reimbursement risks, underpayments, and revenue leakage.
• Partners with finance and revenue cycle to resolve reimbursement discrepancies and payment disputes and supports forecasting, margin analysis, and payor profitability reporting.
• Translates contract terms into operational requirements for pharmacy systems, billing platforms, and claim adjudication logic and coordinates with IT and pharmacy operations to ensure accurate setup of pricing and payor-specific rules (including NDC requirements, J-codes, modifiers, and site-of-care billing logic).
• Supports payor mapping tied to BIN/PCN, NCPDP, NPI, and taxonomy configurations.
• Ensures contracts comply with federal and state regulations including CMS, Medicare Part B and D, Medicaid, 340B, and anti-kickback requirements; maintains audit-ready documentation; and supports internal/external audits.
• Acts as the primary contract resource for internal teams; provides contract education to support accurate billing and payor compliance; and supports payor escalations, access issues, and network participation inquiries.

Minimum Requirements:

Requires a Bachelor’s degree in Business, Healthcare Administration, Finance, or related field and minimum of 5 years of experience in payor contracting, managed care, or contract administration within specialty pharmacy, infusion pharmacy, PBM, or health plan environments; or any combination of education and experience which would provide an equivalent background.

Primary Posting Location Compensation: MIN $111,132 - MAX $166,698

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