11 days old

Manager, Payer Operations – Specialty Pharmacy

Pittsburgh, PA
Job Summary

Responsible for leading and directing activities associated with the operations, implementation and maintenance of executed contracts for third party programs (e.g. retail pharmacy, mail service, specialty pharmacy, infusion, take care retail clinics). Works cross-functionally (e.g. Sales, Store Operations, Marketing, Purchasing, Advertising, Information Technology, Accounting, Finance, Logistics, Distribution and Law) to coordinate contract administration for pharmacy and medical benefit programs including processing, billing, reimbursement, formulary and payment information. Ensures that policies and procedures are revised and implemented to address any operational issues that are identified on the Walgreens side. Knowledge and understanding of products and services, store/field operations and contracts as well as knowledge of the managed care and insurance industries and their respective business issues and potential opportunities.

Job Responsibilities
  • Partners with the management team to identify, develop, and implement appropriate approaches, processes, and tools that elevate the analytics group.
  • Monitors the contract terms and commitments to assure all deliverables are adhered to and take proactive measures before key milestones are missed. Monitors the implementation process for all third party programs, while balancing client needs and company objectives to ensure a successful/positive implementation for both parties. Ensures maximum gross sales and profit by working closely with Contracting Directors/Managers through the ongoing review and confirmation of any non-standard third party plan setup requests. Works with corporate and field on any reimbursement issues, and brings exceptions or non-standard requests to the attention of senior management where appropriate. Maintains communication regarding third party participation, contract compliance, and any other operational issues or opportunities.
  • Manages the tracking, approval, administration, and post-implementation process of all Managed Care contracts throughout the contract life cycle.
  • Works with Contracting Directors/Managers to review Third Party Managed Care Contracts to ensure operational requirements can be met and implemented.
  • Monitors the technical links between the Third Party Provider and data tracking systems to assure reported issues are properly captured, reported, prioritized and managed to closure.
  • Oversees a Third Party Governance Process including periodic status calls, quarterly performance reviews, annual business planning, change order reviews and Third Party budgets/ costs. Conducts periodic meetings/ calls with internal departments to address administration issues, and coordinates resolution with the Service Provider as required.
  • Trains and provides ongoing education to personnel, customers, contractors, etc. on processes and procedures to address Payor related issues, updates, and opportunities. Works with appropriate internal and external parties to load and update new/existing location, market, and provider information.
  • Manages and audits the loading and updates of pricing and reimbursement terms to ensure contract compliance and appropriate profit and reimbursement.
  • Creates and oversees the training schedule of new employees as well as participate in a significant amount of training for new and existing employees. Provides analytical guidance, mentoring, and coaching to the team and peers.

Walgreens, one of the nation's largest drugstore chains, is included in the Retail Pharmacy USA Division of Walgreens Boots Alliance, Inc., the first global pharmacy-led, health and wellbeing enterprise. More than 10 million customers interact with Walgreens each day in communities across America, using the most convenient, multichannel access to consumer goods and services and trusted, cost-effective pharmacy, health and wellness services and advice. Walgreens operates 8,175 drugstores with a presence in all 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands. Walgreens omnichannel business includes Walgreens.com. Approximately 400 Walgreens stores offer Healthcare Clinic or other provider retail clinic services.

As the neighborhood drugstore and retailer, our goal is to make health and happiness simpler, easier and within reach. And we remain a trusted wellness provider offering convenient access to important health services, such as immunizations and an array of pharmacy services that can help patients improve their health. To our team members, Walgreens represents a unique opportunity to excel in their careers in a welcoming and inclusive environment. We offer the chance to work in a truly supportive environment, and be a part of a progressive organization dedicated to the well-being of our customers, team members and the communities we all call home.

Basic Qualifications

  • Bachelor's Degree and at least 2 years of experience in healthcare industry OR High School Diploma / GED and at least 4 years of experience in healthcare industry.
  • At least 2 years of experience in performing a combination of analysis, administration, or operations in the healthcare industry.
  • Experience collaborating with internal and resources to develop strategies that meet department goals within budget and established timelines.
  • Experience with analyzing and reporting data in order to identify issues, trends, or exceptions to drive improvement of results and find solutions.
  • Experience in identifying operational issues and recommending and implementing strategies to resolve problems.
  • Advanced level skill in Microsoft Excel (for example: using AVERAGE function, merging and centering cells, printing centered page and/or creating a pivot table).
  • Intermediate level skill in Microsoft Word (for example: creating and modifying text styles, numbering and sorting lists, working with sections and columns, formatting tables, and using templates and using diagrams and drawing tools)
  • Intermediate level skill in Microsoft PowerPoint (for example: creating presentations, adding and removing slides, entering and formatting text, applying design templates, modifying masters, inserting graphics and objects, creating handouts).
  • At least 1 year of project management
  • At least 1 years of experience planning, developing, and managing departmental expense and capital budgets.
  • At least 1 year experience of cross functional team leadership.
  • Willing to travel up to 15% of the time for business purposes (within state and out of state).

Preferred Qualifications

  • MBA
  • At least 2 years of experience implementing contracted Third Party programs in the healthcare industry.
  • At least 2 years of experience administering healthcare contracts.
  • At least 2 years Payor and facility credentialing experience.
  • At least 2 years of medical reimbursement/fee schedule maintenance experience.
  • Infusion, Specialty Pharmacy, Retail Clinic, and/or Pharmacy Technician experience.
  • Experience using Walgreen proprietary systems (e.g. AS400, SIMS, POS, IC+)
  • At least 2 years of experience working in retail pharmacy operations.
  • At least 2 years of working collaboratively with cross-functional teams.
  • Experience in identifying operational issues and recommending and implementing strategies to resolve problems. This would include using business and analytical skills to facilitate requirement sessions and documenting activity workflows and business requirements. Such process would involve experience in the direct and indirect management of team members, including assisting in the development, training and assignment of work/projects to other team members.


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Manager, Payer Operations – Specialty Pharmacy

Pittsburgh, PA

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Pittsburgh, PA

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