Manager of Managed Care - Kmart Pharmacy
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POST DATE 9/10/2016
END DATE 10/10/2016
Hoffman Estates, IL
JOB DESCRIPTIONThe Provider Network Manager is responsible for evaluating and negotiating pharmacy provider contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls. This candidate will establish and maintain strong business relationships with third party payers, including PBM's,Health Plans, other contracting entities and associations.
Responsibilities include but are not limited to:
* Develops deep understanding of evolving regulatory landscape and competitive market conditions that affect pricing for individual brands, therapeutic areas, and overall industry, and proactively makes recommendations on pricing strategies as related to managed care, reimbursement environment, federal and state regulations.
* Assesses contracting landscape, risk assessment, and shifts in trends or behaviors with key customer segments, including Health Plans, PBMs, SPs, and GPOs. Interprets likely impact and suggests appropriate contracting strategies.
* Drives business analytics to support contract strategy activities and partners with Customer Facing account roles, including National and Regional accounts, and Trade and Distribution Channels.
* Develops implementation and communication plan for innovative contracting, including indication-based and outcomes based contracts with Health Plans and PBMs.
* Works closely with Finance to ensure all contract strategies and offerings have financial justification and sound business judgement, and also assists in assessing the performance of existing contract strategies and offerings.
* Coordinates with operational activities around rebates, chargebacks, government reporting, contract writing, and process approvals.
* Analyze pharmacy network performance to assess performance against contractual requirements
* Evaluate market rates and pharmacy performance (e.g., billing patterns; referral patterns; quality and effectiveness) in order to establish pharmacy rates and negotiation strategies
* Demonstrate understanding of competitor landscape within the market (e.g., rates; market share; products; geo-access)
* Balance financial, operational and regulatory impact of contracting when developing and/or negotiating contract terms
* Demonstrate understanding of contract policies to ensure compliance and consistent contracting
* Demonstrate understanding of contract language and terms of agreement in order to ensure that financial/operational impact and legal implications are aligned with business objectives
* Communicate proposed contractual terms with payers and negotiate mutually acceptable agreement
* Explain the organization's direction and strategy internally and to clients in order to justify methodologies, processes, policies, and procedures
* Represent company in pharmacy meetings
* Implement local, regional, and/or national initiatives and directives through contracting strategies and communication efforts
* Develop and/or implement contracting strategies to support new benefits designs and plans
* Support company in all pharmacy network audits
* Monitor and communicate to the internal pharmacy team network performance from both a profitability perspective and CMS Stars performance.
Required professional experience & Professional Competencies:
* 5+ years of experience in a Network Management-related role handling complex network pharmacies with accountability for business results;
* 5+ years of experience in the Healthcare Industry;
* 2+ years of experience in contributing to the development of product pricing and utilizing financial modeling in making rate decisions;
* Must be able to communicate effectively (read, speak, and write) in English
* Computer proficiency, knowledge of Microsoft Office products, and Internet experience;
* Attention to detail; organizational skills; analytical and critical thinking; superior interpersonal and customer service skills.
Required Education, Training & Licensure / Certifications:
* Bachelor's Degree;
* Required education, training & Licensure/certifications;
* HIPAA, both Security & Privacy; Confidentiality, & Fraud, Waste and Abuse (FWA)*