The Manager of Payor Operations will lead the coordination and management of all aspects of PBM/Payor operations and requirements. This individual will be responsible for overseeing the end-to-end processes of payor credentialing, network enrollment, audits, claims issues, and reimbursement resolution. The ideal candidate will have strong expertise in pharmacy benefit management (PBM), pharmacy administration, payor credentialing, payor audits, and claims adjudication.
This role is critical to our overall service and offerings to pharmacies. We are looking for a well-rounded member to join our team that is seasoned, experienced and knowledgeable in all aspects of payor operations.
This job description is a broad outline of key responsibilities and qualifications, but it is not exhaustive. The Payor Operations Manager may be asked to take on additional tasks as needed to support the organization's overall goals and success.
Essential Functions
Key Responsibilities
- Payor Credentialing & Network Enrollment:
- Lead and manage the payor credentialing and re-credentialing processes for pharmacies.
- Ensure accurate and timely enrollment of pharmacies with payors, including commercial, Medicare, and Medicaid plans.
- Maintain a comprehensive understanding of the payor enrollment requirements for various insurance carriers.
- Work with internal teams to ensure pharmacies are properly enrolled and compliant with payor requirements.
- Audits & Compliance:
- Manage and support audit activities from payors, including overseeing internal audit preparation, documentation, and communications with payor representatives.
- Monitor compliance with payor contracts and regulatory requirements, ensuring adherence to all applicable laws and guidelines.
- Ensure that audits are completed in a timely manner, including managing audit responses and ensuring corrective actions are taken where necessary.
- Communicate with and educate pharmacy personnel on audit processes and strategies to improve audit results.
- Claim Issues & Resolution:
- Oversee the investigation and resolution of pharmacy claims issues, including rejected claims, payment discrepancies, and other billing issues.
- Work closely with payor representatives and pharmacy teams to ensure claims are processed correctly and any discrepancies are addressed.
- Collaborate with the billing department and pharmacy teams to resolve any outstanding issues, minimizing financial impact on the organization.
- Reimbursement Resolution:
- Oversee the resolution of reimbursement issues, including negotiating adjustments or reprocessing of claims when necessary.
- Develop and implement strategies to maximize reimbursement for pharmacies.
- Work with finance and contract management teams to ensure accurate reimbursement and payment reconciliation.
- Team Collaboration:
- Foster strong working relationships with internal teams (e.g., operations, finance, legal) and external payors to ensure smooth communication and issue resolution.
- Collaborate with leadership to develop process improvements and drive operational efficiencies.
- Reporting & Analysis:
- Regularly track and report on key metrics such as credentialing status, audit outcomes, claim rejection rates, and reimbursement trends.
- Analyze trends and provide insights and recommendations to senior management regarding payor performance and network performance.
- Present findings to leadership and stakeholders.
- Compliance & Quality Assurance:
- Ensure adherence to federal, state, and payor-specific regulations for pharmacy credentialing and operations.
- Implement quality assurance measures to maintain data accuracy and operational compliance.
- Conduct regular audits to identify gaps and mitigate risk.
- Manage fulfillment of all requirements, including with State and Federal agencies to include credentialing for all existing pharmacy locations.
- Oversee all processes related to the organization, maintenance, and verification of the credentialing for pharmacy customers.
- Communicating new credentialing requirements as the same are introduced, such as those specific to Specialty fulfillment, heat zones, etc.
Education And Experience
Basic Requirements
- 7 + years of experience in payor credentialing, payor operations, network enrollment, claims adjudication, reimbursement, or pharmacy audit (Required)
- 5+ years of experience in payor relations, pharmacy operations, specialty pharmacy, or healthcare payor management (Required)
- Prior experience working with pharmacy benefit managers (PBMs), insurance companies, or a PSAO (Required)
- Specialty pharmacy experience (Required)
- PSAO knowledge and experience (Required)
- Active Nationally Certified Pharmacy Technician (CPhT): PTCB or NHA accepted.(Required)
Additional Requirements
- Travel up to 30% (Required)
Preferred Qualifications
- Associate’s or Bachelor’s degree in Healthcare or a related field
- Thorough knowledge of state and federal regulatory guidelines related to pharmacy
Skills & Knowledge
- Strong understanding of payor credentialing, PBM operations, pharmacy administration, regulatory requirements, payor audits, reimbursement policies, PBM contracts, and payor networks
- Excellent problem-solving skills with the ability to resolve complex claim and reimbursement issues
- Strong communication and analytical skills
- Ability to manage multiple priorities in a fast-paced environment
- Exceptional communication and negotiation skills to collaborate with internal teams and external stakeholders
- Proficiency in Microsoft Office Suite (especially Excel)
- Experience with credentialing portals and pharmacy management systems
Key Performance Indicators (KPIs)
- Timeliness of pharmacy credentialing and re-credentialing submissions
- Accuracy and completeness of pharmacy payor enrollment and data
- Turnaround time for resolving payor/PBM issues
COMPETENCIES
- Demonstrates initiative, professionalism, punctuality, and efficiency
- Ability to multitask and perform well under pressure in both remote and in-office environments
- Proactive, responsive, and resourceful with strong follow-up and organizational skills
- Flexible and motivated, with the ability to work independently and within a team
- Strong interpersonal skills with the ability to engage effectively across all levels of the organization
- Excellent computer skills in a Microsoft Windows environment
- Maintains a high level of confidentiality and discretion
- Ability to execute on strategic plans and drive results
- Builds and leverages key relationships
- Strong problem-solving, analytical, and strategic thinking capabilities
- Demonstrates technical proficiency, integrity, and motivation
