Provider Relations Manager

Insight Health System Insight Health System is a physician‑led organization focused on advancing excellence in healthcare and community well‑being. Our expertise is in transforming distressed hospitals into stable, patient‑centric care that is second to none. With a track record for innovation in healthcare, research and development, Insight Health System provides the communities we serve with world‑class healthcare services at the forefront of medical technology. Our network currently includes a portfolio of entities encompassing six acute care hospitals (three of which are nonprofit), six surgery centers, 28 clinics, 580 physicians, 10 unions, and 4,200 employees. Collectively, Insight Health System hospitals provide nearly 100,000 patient days annually. Position Overview We are seeking a proactive, relationship‑driven PBM Partnerships & Payer Relations Manager to serve as the primary point of contact for Pharmacy Benefit Managers (PBMs), third‑party administrators (TPAs), brokers, and self‑funded employer groups. This role is responsible for building new partnerships, strengthening existing relationships, supporting contract execution, ensuring operational accuracy, and driving network growth across all payer and PBM channels. The ideal candidate excels at communication, problem‑solving, and business development within the pharmacy or healthcare benefits ecosystem. Benefits Comprehensive health, dental, and vision insurance Paid time off: vacation, holidays, and sick leave 401(k) with employer match (immediate vesting; eligibility begins after 3 months) Employer‑paid short‑term and long‑term disability, basic life insurance Voluntary coverages: accident, critical illness, hospital indemnity, AD&D, etc. Key Responsibilities PBM Partnership Management Serve as the main liaison for all PBM partners, contractors, TPAs, and associated vendors. Manage onboarding, implementations, and ongoing communication to ensure alignment and strong operational performance. Oversee contract execution, version control, and escalation resolution with external partners. Proactively step in to assist with prior authorizations or operational duties as needed to ensure exceptional service continuity. Maintain a clear understanding of PBM reimbursement strategies, plan designs, MAC pricing, and specialty pharmacy dynamics. Step in to assist with PAs or operations during high‑volume periods or staffing gaps. Self‑Funded Employer Network Development Build new relationships with self‑funded employers, brokers, benefits consultants, and employer coalitions. Identify opportunities for employers to utilize the pharmacy as a preferred or direct‑to‑employer solution (specialty savings, infusion savings, carve‑outs). Present pharmacy value propositions, cost‑savings models, and service offerings to employer groups. Support the execution of direct‑to‑employer agreements and develop customized employer workflows. Payer & Network Growth Drive expansion into new PBM networks, payer groups, and employer health plans. Research and pursue opportunities to improve reimbursement rates or negotiate favorable contract terms. Track market trends, competitive pricing, and plan changes influencing pharmacy performance. Strengthen ties with existing PBM and payer partners to secure long‑term relationships. Operational & Contract Coordination Troubleshoot operational issues, adjudication errors, reimbursement discrepancies, and network constraints. Collaborate with internal teams (legal, finance, operations, pharmacy) to ensure contractual accuracy and workflow alignment. Maintain oversight of contract renewals, amendments, compliance obligations, and key dates. Support renegotiation efforts by preparing comparisons, contract reviews, and partner summaries. Performance Monitoring & Reporting Track reimbursement patterns, adjudication behaviors, specialty margins, and PBM performance metrics. Generate internal reporting to evaluate partnership effectiveness and financial outcomes. Identify opportunities to optimize pricing strategies, improve patient access, and enhance profitability. Relationship Building & Strategic Development Cultivate strong, trust‑based relationships with PBM executives, employer decision‑makers, consultants, and industry partners. Represent the organization at meetings, conferences, and strategic discussions. Identify emerging opportunities for collaboration, market expansion, or product/service enhancement. Required Qualifications Bachelor’s degree in Business, Healthcare Administration, Pharmacy, or a related field. Experience working with PBMs, payers, networks, benefits administrators, or pharmacy operations. Strong communication, negotiation, and relationship‑management skills. Ability to manage contracts, escalations, timelines, and multi‑stakeholder relationships. Strong analytical thinking, problem‑solving skills, and organizational abilities. Preferred Qualifications Prior experience working directly with PBMs, TPAs, or self‑funded employer groups. Experience in specialty pharmacy, infusion services, or pharmacy network contracting. Working knowledge of claim adjudication, reimbursement structures, MAC lists, spread pricing, and DIR fee models. Experience building direct‑to‑employer pharmacy programs or benefit carve‑out models. Familiarity with value‑based pharmacy programs, outcomes reporting, and data‑driven performance metrics. Strong understanding of healthcare contracting, payer policies, and benefits administration. Ability to interpret contract terms, fee schedules, and reimbursement methodologies. Experience presenting pharmacy solutions or savings programs to employers, payers, or consultants. Existing relationships with PBMs, benefit brokers, employer groups, or industry partners is a major plus. Insight is an equal opportunity employer and values workplace diversity. #J-18808-Ljbffr