Advisor, Network and Payor Relations (MAC Support)

Network and Payor Relations

At Cardinal Health, the marketing organization is the central hub of business driving activity. Marketing takes the lead on all aspects of the marketing mix product, price, place, people and promotion. Marketing analyzes customer behavior to understand their needs, and motivations, broadly defines and communicates the brand purpose and passionately delivers total solutions for our customers.

Network and Payor Relations is responsible for the development and management of business relationships with Pharmacy Benefit Management (PBM) companies and Health Plans. Responsibilities include contracting activities, network and performance participation for Cardinal Health and its Pharmacy Services Administrative Organizations (PSAOs). This involves identifying and evaluating strategic opportunities for all lines of business including Medicare, Medicaid, and various commercial markets. Key responsibilities include managing the appeal process, analyzing data to identify pricing issues, ensuring regulatory compliance, maintaining communication with stakeholders like pharmacies and PSAO leadership, and improving the MAC appeals process. This role is critical for ensuring fair pricing and adherence to state and federal laws governing PBM practices.

Responsibilities :

Coordinate and manage the entire MAC appeals process, from initiating an appeal to resolving the dispute

Analyze data and identify trends related to MAC pricing and provide insights to leadership.

Monitor and ensure the MAC appeal response adheres to all applicable state and federal laws, statutes, and regulations.

Serve as a point of contact for pharmacies, providing updates and clarifying information regarding MAC appeals and pricing

Proactive problem-solving skills to identify and address issues within the MAC appeals process.

Strong ability to analyze data, identify discrepancies, and draw actionable conclusions regarding MAC pricing.

Demonstrates basic knowledge of network and payor concepts and applies an understanding of managed care trends to support the review and resolution of appeals and pricing discrepancies.

Exhibits strong financial acumen and logical decision-making skills in the general business environment. Understands and demonstrates sound thought processes as they relate to pricing and assessing gross margin / profitability.

Reviews and validates managed care contracts to ensure compliance with organizational policies, regulatory requirements and contractual standards.

Exhibits an ability to translate market and customer needs into clearly defined goals, objectives, strategies, and tactics to drive sales and profitability for the business. Accountable for gaining and driving cross functional support from all stakeholders.

Identifies and remains current on payor market and reimbursement trends. Determines product / service lifecycle implications and makes recommendations to maintain market competitiveness to achieve sustainable economic success.

Understands methods available to execute primary research necessary to drive business decisions. Can identify market opportunities through analysis of network performance and compliance, taking action to implement and manage solutions that meet customer needs.

Understands the regulatory environment surrounding payor relations, reimbursement, and health policy.

Works effectively across cross functional groups including but not limited to IT, communications, operations, sales, and finance.

Applies comprehensive knowledge and a thorough understanding of concepts, principles, and technical capabilities to perform varied tasks and projects.

May contribute to the development of policies and procedures.

May act as a mentor to less experienced colleagues.

Completes work independently; receives general guidance on new projects.

Qualifications :

Bachelor's degree in related field, or equivalent work experience, preferred

5 years experience, preferred

Strong communication and analytical skills preferred

Extensive understanding of Managed Care, PBM networks and Pharmacy industry trends preferred

Must have experience with Microsoft Office (Word, Excel, and Power Point specifically)

Previous pharmacy experience is a plus

PSAO / Managed Care experience is a plus

What is expected of you and others at this level :

Applies comprehensive knowledge and a thorough understanding of concepts, principles, and technical capabilities to perform varied tasks and projects

May contribute to the development of policies and procedures

Works on complex projects of large scope

Develops technical solutions to a wide range of difficult problems

Solutions are innovative and consistent with organization objectives

Completes work independently; receives general guidance on new projects

Work reviewed for purpose of meeting objectives

May act as a mentor to less experienced colleagues

Anticipated pay range : $67,500-$86,670

Bonus eligible : Yes

Benefits : Cardinal Health offers a wide variety of benefits and programs to support health and well-being.

Medical, dental and vision coverage

Paid time off plan

Health savings account (HSA)

401k savings plan

Access to wages before pay day with myFlexPay

Flexible spending accounts (FSAs)

Short- and long-term disability coverage

Work-Life resources

Paid parental leave

Healthy lifestyle programs