Travel: Incidental travel required

Scope of Responsibilities:  Oversight responsibility for the managed care department of the company. Responsible for training, development and conducting performance reviews of subordinate staff, estimating personnel needs, assigning work, meeting completion dates, interpreting and ensuring consistent application of organizational policies.

Job Summary: Responsible for analyzing benefits and reimbursement structures, developing strategies to improve margins, and negotiating favorable terms with pharmacy benefit managers (PBMs) and other third-party payers.

Job Duties:

• Review and interpret third-party payer contracts, fee schedules, and reimbursement terms.
• Analyze payer benefit structures, reimbursement trends, and payment integrity issues.
• Identify underpayment trends, benefit discrepancies, or areas for improved reimbursement and present actionable recommendations to leadership.
• Serve as the primary contact for PBM contract negotiations.
• Prepare financial models and business cases to support negotiation strategies.
• Negotiate reimbursement rates, discount structures, and incentive terms with PBMs and other payers.
• Maintain and nurture strong working relationships with PBM representatives and payer partners to ensure favorable contract outcomes and resolve disputes efficiently.
• Monitor contract compliance, escalate disputes, and drive resolution of reimbursement issues.
• Work closely with the Executive Team, Pharmacy Operations, and Finance teams to ensure accurate implementation of contract terms.
• Partner with legal counsel to review and draft contract amendments.
• Stay up to date with federal and state reimbursement regulations, PBM trends, and payer policy changes.
• Develop internal best practices and educate stakeholders on third‑party payer requirements.
• Monitor industry trends, regulatory changes, and PBM market dynamics.
• Responsible for completing all mandatory and regulatory training programs.
• Perform other duties as assigned.

Education:

• Minimum: AS in Business Management, or related field
• Preferred: BS in Business Management

Experience:

• Required: 3 to 5 years Pharmacy operations and reimbursement

Special Conditions of Employment: 

• Drug test
• Initial and continuous exclusion and sanction/disciplinary monitoring
• Any and all additional eligibility requirements based on the specific position

Compensation:

$95,000-98,000 Annually

The final offer will be determined after careful consideration of multiple factors such as relevant skills, years of experience and education.  

KPH Healthcare Services, Inc. is a multistate organization and abides by all local, state and federal regulations as it pertains to minimum wage requirements.