At CSI Pharmacy (CSI), we are on a mission to provide Specialty Pharmacy services to patients with chronic and rare illnesses in need of complex care. CSI is a rapidly growing national Specialty Pharmacy. Whether you work directly with patients or behind the scenes in support of the business and its employees, you will use your expertise, experience, and skills to support our patients and our mission.
Summary:
The Director Pharmacy Benefit Manager is responsible for the evaluation, negotiation, implementation, credentialing, and ongoing management of managed care and Pharmacy Benefit Manager (PBM) agreements with new and existing health plans, payers, and managed care organizations. This role is focused on securing financially advantageous and operationally sustainable contract terms while strengthening strategic relationships across the healthcare ecosystem. In addition, the Director Pharmacy Benefit Manager will provide leadership in the sales, account management, implementation, and operational oversight of PBM services for large national clients, including health plans, employers, insurers, third-party administrators, and government entities. The ideal candidate possesses a strong understanding of specialty pharmacy reimbursement, payer contracting, Medicare and Medicaid programs, and healthcare revenue cycle operations.
Compensation Range: $150,000 - $180,000/yr (DOE)
Schedule: (Remote) Monday - Friday, 8:00am - 4:30pm CST or EST with some flexibility
Location: The ideal candidate will reside in either a CST or EST state
Travel:
25-30% travel for various conferences (4-6xs/year) which includes local travel, as needed
Essential Duties and Responsibilities:
include the following. Other duties may be assigned, as necessary. Lead the growth and strategic development of the Company's PBM business, including client acquisition, implementation, retention, and expansion initiatives. Lead the negotiation, implementation, and ongoing administration of managed care across the assigned region. Develop and maintain processes to ensure timely dissemination of contract terms, reimbursement methodologies, operational requirements, and payer updates to key stakeholders. Manage all phases of the contract lifecycle, including evaluation, negotiation, approval, implementation, monitoring, renewal, amendment, and termination activities. Analyze contract performance and reimbursement trends to identify opportunities for revenue optimization and operational improvement. Maintain a comprehensive understanding of Medicare, Medicaid, commercial payer reimbursement methodologies, pharmacy benefit design, and provider payment structures. Serve as the primary point of contact for payer relations and contract performance management. Collaborate with leadership, revenue cycle, operations, billing, pharmacy, compliance, and credentialing teams to ensure successful contract implementation and ongoing compliance. Develop and strengthen relationships with medical and pharmacy benefit plans to secure competitive reimbursement rates and favorable contract language. Oversee payer credentialing and recredentialing activities to ensure uninterrupted network participation. Assist operational teams with payer-related issues, including prior authorizations, eligibility verification, referrals, enrollment requirements, billing concerns, and payer education initiatives. Monitor payer compliance with contract terms and address reimbursement, operational, or performance issues as they arise. Identify market opportunities and support growth initiatives through strategic payer engagement and business development activities. Regularly communicate payer trends, reimbursement changes, regulatory developments, and network opportunities to leadership. Represent the company professionally in all interactions with payers, clients, providers, and industry stakeholders. Maintain effective working relationships with colleagues across all departments. Adhere to all company policies, compliance requirements, regulatory standards, and applicable federal and state laws. Perform other duties and responsibilities as assigned. Qualification Requirements
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Establish and maintain a system of reviewing and assessing changes in the Federal and or State regulations regarding Managed Care contracts Provide the highest level of professionalism, responsiveness, and communication in order to build and maintain the maximum customer base possible Must possess the ability to multi-task and frequently change direction. Experience Bachelor’sDegreepreferredor 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 in managing, analyzing, and reporting denials and appeals. JR# JR258409
