Director, Pharmacy Benefit Manager

Job not on LinkedIn

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $150k - $180k / year

⏰ Full Time

🔴 Lead

💊 Pharmacist

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CSI Pharmacy

WebsiteLinkedInAll Job Openings

51 - 200 employees

💼 Consulting

🛡️ Insurance

🏥 Healthcare

Consulting • Insurance • Healthcare

CSI Pharmacy is a nationwide specialty pharmacy that focuses on providing services and therapies for patients with chronic and rare illnesses requiring complex care. Founded by pharmacists, the company is dedicated to improving the health and lives of its patients by offering individualized infusion therapies, specialized pharmaceutical knowledge, and passionate patient advocacy. With a presence across the country, CSI Pharmacy offers services such as nursing, pharmacy services, insurance and reimbursement navigation, and patient advocacy, aiming to treat each patient with personalized attention. The company specializes in treating rare diseases with biologics and plasma-derived therapies and is committed to optimizing patient outcomes in the comfort of their homes.

📋 Description

• 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