Payor and PBM Specialist

Welcome to Clearway Health- a recognized Great Place to Work and destination organization! We arean 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. AtClearwayHealth, we take great pride in our High Five! Values to provide best in class experiences for ouremployees, ourclients and their patients. We welcome you to follow us on LinkedIn where you can also learn more about ourcompany, culture,people, andcareers.

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 offering 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:

• Negotiate and manage contractual agreements with national and regional payors and PBMs to gain and retain in-network access, understand 340B pricing and requirements.
• Evaluate network participation criteria and lead submissions to meet access requirements, including credentialing, accreditation, and performance standards.
• Collaborate with legal, compliance, and finance teams to ensure contract terms are favorable and align with regulatory and operational standards.
• Maintain a comprehensive understanding of formulary structures, access restrictions, and rebate strategies that impact specialty pharmacy access.
• Serve as the primary liaison with payors and PBMs regarding contract performance, dispute resolution, and renewals.
• Analyze reimbursement rates, performance guarantees, and payer policies to optimize contract value and operational efficiency.
• Monitor the evolving healthcare policy and regulatory environment, including impacts from the Inflation Reduction Act (IRA), Medicare, and state-level changes.
• Support business development by identifying new network opportunities and assisting with the launch of limited-distribution drug programs.
• Prepare reports and dashboards to communicate contract status, payer mix trends, and access barriers to internal stakeholders.

JOB REQUIREMENTS:

• 5+ years of experience working in the health insurance or PBM industries is required.
• Deep understanding of the specialty pharmacy landscape, including payor networks, reimbursement structures, 340B, and regulatory requirements.
• Proven negotiation skills and experience managing complex contracts across multiple stakeholders.
• Strong analytical and communication skills with the ability to translate complex contractual data into actionable insights.

EDUCATION:

• A Bachelor's degree in business administration, healthcare administration, or a related field is a requirement
• Master's degree is highly desired.
• Pharmacy industry experience is highly desired.
• Knowledge of accreditation standards (URAC, ACHC) is a plus

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• N/A

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%.