Pharmacy Contract Negotiator Senior

Duties and Responsibilities

Remote Work Capable

Essential Functions:

• Cultivates and maintains collaborative relationships with PBMs, health plans, and pharmacy network representatives, as well as internal pharmacy and revenue cycle teams.
• Leads all stages of pharmacy contract negotiations to ensure payment methodologies, dispensing fees, specialty reimbursement structures, DIR/GER terms, performance programs, and operational requirements are favorable and manageable.
• Manages an assigned portfolio of pharmacy contracts, including commercial prescription plans, Medicare Part D, Medicaid FFS/managed care programs, specialty pharmacy networks, and limited distribution drug network (LDD) opportunities.
• Analyzes the financial impact of proposed changes to reimbursement rates, MAC pricing, specialty tiers, performance metrics (e.g., adherence, gaps in care), audit provisions, credentialing, and payment timelines. Recommend adjustments or counterproposals as needed.
• In collaboration with pharmacy operations, finance, and compliance teams, ensures the organization can operationalize proposed contract changes and that final language accurately reflects negotiated terms.
• Maintains ongoing knowledge of PBM policies, network changes, CMS regulations, Medicaid pharmacy rules, specialty pharmacy accreditation requirements (URAC, ACHC), and industry contracting trends.
• Supports strategic system initiatives such as expanding specialty pharmacy services, pursuing limited distribution contracts, enabling white/brown/clear bagging, and optimizing retail pharmacy profitability.
• Monitors external market activity including PBM mergers, pharmacy network restructuring, reimbursement shifts, and state/federal policy changes impacting pharmacy reimbursement.
• Conducts research and prepares summaries, financial models, or reports related to pharmacy contract opportunities, risks, or strategic initiatives.
• Participates in internal committees, cross-functional teams, and annual education programs
• As needed, leads contracting efforts for pharmacy-related services (e.g., infusion, home delivery, DME, vaccines, clinical pharmacy initiatives).
• Independently manages priorities, negotiates timelines, and executes strategies with minimal supervision.
• Develops and oversees free-market drug access strategy.

Common Expectations:

• Continuously assesses PBM and payer performance using audits, denial trends, reimbursement variance analysis, and performance program results.
• Supports continuous improvement within the pharmacy contracting and revenue cycle functions, recommending workflow enhancements or compliance improvements.
• Promotes teamwork, maintains professionalism, and supports organizational values and compliance standards.
• Maintains strict confidentiality regarding proprietary payer terms, pricing models, and pharmacy performance data.

Travel Requirements:

• Estimated Amount: 10% - Regional travel (payer meetings, site visits, conferences)