Summary
This role is responsible for managing and optimizing relationships with Pharmacy Benefit Managers (PBMs) on behalf of our PSAO network, with a focus on contract execution, network administration, and dispute resolution. The Account Manager plays a key role in overseeing PBM network contracting, reconciliation analysis, and coordinating with internal legal teams to resolve contract and reimbursement disputes. Additional responsibilities include tracking credential status across the PSAO network, facilitating resolutions to network rejections, and ensuring compliance with all contractual obligations. This position requires deep knowledge of PBM operations, exceptional attention to detail, and the ability to communicate effectively with both internal stakeholders and external partners.
Essential Duties and Responsibilities
This list of duties and responsibilities is not all inclusive and may be expanded to include other duties and responsibilities as management may deem necessary from time to time.
- Manage and maintain relationships with PBMs, ensuring clear communication and swift resolution of issues related to network participation, claims processing, and formulary adherence.
- Review and interpret PBM contracts to identify risks, assess financial impact, ensure compliance with reimbursement terms, and support negotiation strategy.
- Review existing contracts for deviations from template language; document terms in a database and maintain template comparison charts, defined parameters, and a matrix of provision deviations.
- Facilitate resolution of claim rejections, terminations, and other network access issues by coordinating directly with PBMs and impacted pharmacies.
- Lead contract negotiation discussions with PBM representatives to secure favorable terms for the PSAO network, including reimbursement rates, operational feasibility, reconciliation terms, and credentialing requirements.
- Collaborate with Legal to monitor CMS guidance and applicable state law provisions impacting PBMs and pharmacy benefits.
- Collaborate with the Legal team to identify and mitigate compliance risk areas associated with PBM pharmacy/provider manuals.
- Collaborate with Analytics team to Conduct detailed reconciliation analyses to identify underpayments, overpayments, and adjudication discrepancies; collaborate with PBMs and internal teams to resolve payment variances.
- Lead the NCPDP related onboarding process for new PSAO clients, ensuring a smooth and efficient transition by collaborating with internal teams and aligning with client expectations.
- Manage existing PBM contracts to ensure compliance by all parties; partner with internal legal counsel to support resolution of contractual disputes and reimbursement conflicts with PBMs.
- Maintain detailed records of PBM interactions, contracts, reimbursement terms, and issue resolutions in platforms such as Salesforce and Monday.com.
- Support leadership with development and auditing of internal department policies and procedures.
- Adhere to company policies and procedures and maintain strict confidentiality of sensitive business and financial data.
- Perform other duties as requested or required.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- At least two years’ prior experience in a client-facing or vendor facing role such as sales or account management, preferably in a healthcare company.
- Bachelor’s degree or equivalent strongly preferred.
- Well-organized and detailed with the ability to communicate in an appropriate and timely manner.
- Ability to write and interpret correspondence, reporting and analytics.
- Ability to speak effectively to clients in person and over the phone with high level of energy, attentiveness, honesty and overall sociability.
- Preferable experience in the pharmacy or pharmacy benefit management industry.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. (The phrases “occasionally,” “regularly,” and “frequently” correspond to the following definitions: “Occasionally” means up to 1/3 of working time, “regularly” means between 1/3 and 2/3 of working time, and “frequently” means 2/3 and more working time.)
While performing the duties of this job, the employee is frequently required to sit, talk or hear and use hands to handle, or touch objects or controls. The employee is regularly required to stand and walk. On occasion the incumbent may be required to stoop, bend or reach above the shoulders. The employee would rarely need to lift up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
Work Environment
The position is based in either our Milwaukee, WI or Denver, CO office 2-4 days a week with up to 2 days a week remote pending satisfactory performance. The role has limited travel (10% or less).
The above statement reflects the general details necessary to describe the principal functions of the occupations describes and shall not be construed as a detailed description of all the work that may be inherent in the occupation
EEO Statement
SPS Health, LLC, and all its affiliates, are equal opportunity employers committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. The Company makes hiring decisions based solely on qualifications, merit, and business needs at the time. The Company complies with the Colorado Healthy Families & Workplaces Act.
