Payor and PBM Specialist

Welcome to Clearway Health - a recognized Great Place to Work® and destination organization! We are an award-winning culture where talented people are respected, informed, engaged, empowered, developed – and where they want to grow and make a difference. We offer a wide range of benefits, perks and wellness programs in addition to continuous learning opportunities to help you grow. At Clearway Health, diversity, equity, inclusion and belonging are an essential part of our business and workplace culture. Clearway Health emerged as a solution from Boston Medical Center to improve access to care, provide personal support and manage the complex specialty medication needs of vulnerable patients and their families. We partner with hospitals, health systems and the communities they care for to accelerate their specialty pharmacy programs.  At Clearway Health, we take great pride in our High Five! Values to provide best in class experiences for our employees, our clients and their patients. We welcome you to follow us on LinkedIn where you can also learn more about our company, culture, people, and careers.

POSITION SUMMARY:

You will be a crucial member of our team acting as a liaison between payers, Pharmacy Services Administration Organizations (PSAOs), and Pharmacy Benefit Managers (PBMs)/third-party administrators of prescription drug programs. As a Business Subject Matter Expert, you will lead the efforts in tackling any reimbursement challenges while evaluating trends and policies and offer solutions. In addition to partnering with cross-functional teams internally, you will navigate both the payer and administrator side by cultivating relationships with a strong focus on customer service. You will enhance current processes, optimize workflows, and maximize profitability.

ESSENTIAL RESPONSIBILITIES/DUTIES:

• You collaborate with Clearway teams and health system partners to address payer, PSAOs and PBMs access and reimbursement challenges, tracking data and troubleshooting with internal and external teams.
• You recommend and educate internal and external partners on reimbursement opportunities and potential solutions.
• You build effective working relationships with national and local payers, PBMs, and PSAOs, ensuring preferred access to their networks through influence and negotiation.
• You review reimbursement rates and recommend improvements as necessary, keeping up to date with current best practices.
• You evaluate managed care trends, coverage patterns, and payer policies, providing information and education to Clearway and health system partners as needed.
• You attend corporate and site-based committee meetings, as well as other ad hoc meetings with health system personnel, to assess needs, communicate progress on specific projects, and develop relationships.
• You maintain a thorough knowledge of payer policies and industry developments related to specialty pharmaceuticals.
• You design and deploy plans, programs, and processes that optimize workflows and maximize profitability.

EDUCATION:

• A Bachelor's degree in business administration, healthcare administration, or a related field is a requirement, and a Master's degree is preferred.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• N/A

EXPERIENCE:

• 5+ years of experience working in the health insurance or PBM industries is required.
• Pharmacy industry experience is highly desired.

KNOWLEDGE AND SKILLS:

• Possess strong verbal and written communication skills, suitable for interaction across all organizational levels and external contacts.
• Demonstrate advanced knowledge and experience in strategic sourcing processes and methodologies.
• Display expertise in contract structures, terms, conditions, and risk mitigation, with a proven track record in executing and drafting business requirements and key performance indicators.
• Proficiently use Microsoft Word, Excel, PowerPoint, and Outlook.
• Exhibit the ability to organize and prioritize work effectively to achieve specific deliverables in a fast-paced environment with tight deadlines and competing priorities.
• Ability to influence, build and maintain effective relationships with critical external partners and payors which ultimately impacts the business.

Special Working Conditions (On-call, travel, shift, coverage):

• This position may require domestic travel up to 20%.