Hybrid Payor Contracts Lead - Specialty Pharmacy

Elevance Health; Mason (OH); Ibrido; USD 111.000 - 167.000; Tempo pieno

Vantaggi offerti da questo lavoro

Hybrid work model

Competitive benefits

Descrizione del lavoro

Elevance Health is seeking a Payor Contract Manager (Specialty Pharmacy) to oversee the contract lifecycle, analyze reimbursement methods, and ensure compliance across commercial, Medicare, and Medicaid lines. The hybrid role collaborates with finance, IT, and pharmacy operations to implement pricing rules and accurate payor-specific billing logic.

The position requires a Bachelor’s degree and 5+ years in payor contracting or related fields, with a focus on specialty/pharmacy environments and

Competenze

• 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.
• Experience serving as SME on contract terms including reimbursement methodologies, fee schedules, carve-outs, drug-level pricing, and site-of-care requirements.
• Ability to analyze reimbursement methodologies (AWP, WAC, ASP, MAC, per diem, case rates, nursing fees, supplies, admin fees) and identify revenue risks.

Mansioni

• 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 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.

Conoscenze

Contract management

Contract analysis

Reimbursement analysis

Regulatory compliance

Cross-functional collaboration

Formazione

Bachelor's degree in Business, Healthcare Administration, Finance, or related field

Strumenti

Pharmacy systems

Billing platforms

Descrizione del lavoro

Elevance Health is seeking a Payor Contract Manager (Specialty Pharmacy) to oversee the contract lifecycle, analyze reimbursement methods, and ensure compliance across commercial, Medicare, and Medicaid lines. The hybrid role collaborates with finance, IT, and pharmacy operations to implement pricing rules and accurate payor-specific billing logic.

The position requires a Bachelor’s degree and 5+ years in payor contracting or related fields, with a focus on specialty/pharmacy environments and