Case Manager providing intensive support to high - needs individuals transitioning from prison back into the community. Collaborating with prisoners and agencies to aid stability and independence.
About the role
- Payor Contract Manager managing contracts for specialty pharmacy, overseeing compliance and reimbursement methodologies, and supporting internal teams. Requires a bachelor’s degree and 5 years of experience in managed care.
Responsibilities
- 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
- 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
Requirements
- Requires a Bachelor’s degree in Business, Healthcare Administration, Finance, or related field
- Minimum of 5 years of experience in payor contracting, managed care, or contract administration within specialty pharmacy, infusion pharmacy, PBM, or health plan environments
- Any combination of education and experience which would provide an equivalent background
Benefits
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical
- dental
- vision
- short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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