Director of PBM Contracting at giftHEALTH

Columbus, Ohio, United States -

Full Time

Start Date

Immediate

Expiry Date

10 Sep, 26

Salary

200000.0

Posted On

12 Jun, 26

Experience

10 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

PBM Contract Negotiation, Payer Relations, Pharmacy Reimbursement, Audit Management, Compliance Monitoring, Financial Modeling, Team Leadership, Rate Validation, MAC Pricing, AWP Discount Schedules, Network Access Terms, Cross-functional Collaboration, CMS Part D Regulations, Specialty Pharmacy Operations, Contract Lifecycle Management, Data Analysis

Industry

technology;Information and Internet

Description

Description Position Summary We are seeking a Director of PBM Contracting to join our Gifthealth team. Reporting to the Chief Legal Officer, this role serves as Gifthealth’s primary point of contact with all PBM partners and owns the full PBM contracting lifecycle, including negotiation of new and renewal agreements, reimbursement integrity and rate validation, compliance monitoring, and audit response. This position plays a key role in Payer Relations / Revenue Operations, ensuring alignment with organizational goals, operational excellence, and compliance standards. Gifthealth’s direct-to-patient model operates across multiple payer networks, and the terms we hold with our PBM partners directly shape our reimbursement rates, network eligibility, and compliance posture. The Director of PBM Contracting will build and lead a small team, work cross-functionally with pharmacy operations, finance, compliance, and technology, and ensure our PBM relationships are both commercially optimized and operationally sound. Key Responsibilities PBM Contract Negotiation: Lead all PBM contract negotiations on behalf of Gifthealth, including new network agreements, renewals, amendments, and specialty contract structures. Develop negotiation strategies that optimize reimbursement rates, MAC appeals rights, network access terms, dispensing fee structures, and audit provisions. Own the full contract lifecycle from initial terms through execution and ongoing performance monitoring. Primary PBM Relationship Ownership: Serve as Gifthealth’s named point of contact with all PBM partners, including commercial, Medicare Part D, Medicaid managed care, and specialty PBMs. Build and maintain active working relationships with PBM contracting, network, and compliance teams. Represent Gifthealth professionally and authoritatively in every PBM interaction. Reimbursement Integrity and Rate Validation: Own the process for validating that Gifthealth is receiving accurate reimbursements consistent with contracted terms across all PBM networks. Monitor adjudication data for rate anomalies, underpayments, and clawback patterns. Coordinate with pharmacy operations and finance to resolve discrepancies and recover owed reimbursements. PBM Compliance Management: Ensure Gifthealth’s operations remain in continuous compliance with PBM network agreements, provider manuals, credentialing requirements, and performance standards. Monitor for contract amendments or policy updates from PBM partners and translate requirements into internal operational actions with appropriate lead time. Audit Support and Response: Serve as Gifthealth’s lead for PBM-initiated audits, coordinating evidence collection, preparing response documentation, communicating with PBM audit teams, and managing remediation. Work proactively to reduce audit risk through internal controls, documentation standards, and pre-audit readiness reviews. Team Leadership: Build and lead a team of PBM Contracting Specialists and Analysts. Assign and manage workload across the PBM portfolio, develop team expertise in contract analysis and payer relations, and create internal processes and tools that scale with Gifthealth’s growing network of PBM relationships. Continuing Education and Market Intelligence: Maintain an active continuing education posture across PBM contracting, reimbursement policy, pharmacy network legislation, and CMS guidance. Attend industry conferences, participate in pharmacy association forums, and leverage PBM partner relationships to stay ahead of changes that affect Gifthealth’s contract terms or compliance obligations. Cross-Functional Collaboration: Partner with pharmacy operations on network credentialing and compliance execution; with finance on reimbursement forecasting and per-dispense economics modeling; with technology on claims and adjudication data infrastructure; and with compliance and legal on contract review and regulatory interpretation. Qualifications Education: Bachelor’s degree or equivalent experience required; degree in healthcare administration, pharmacy, business, or a related field preferred. Experience: 8+ years of experience in PBM contracting, payer relations, pharmacy reimbursement, or pharmacy network management; direct, hands-on experience negotiating PBM contracts; 3+ years in a role with direct PBM negotiation accountability; experience managing PBM audits through resolution; experience working in or on behalf of a specialty pharmacy or mail order pharmacy operation. Licensure/Certification: Not required. Pharmacist (RPh or PharmD) licensure or Certified Pharmacy Technician (CPhT) with deep payer-side experience preferred. Active participation in pharmacy association PBM forums or contracting continuing education preferred. Skills (Required): Demonstrated familiarity with PBM contract economics including MAC pricing, AWP discount schedules, dispensing fees, network access terms, and audit provisions; strong analytical skills and ability to work with adjudication data to identify reimbursement discrepancies and model contract financial impact; track record of building and maintaining productive relationships with PBM contracting and network teams; ability to translate payer obligations into operational priorities and hold cross-functional teams accountable. Skills (Preferred): Experience in a DTP pharmacy model or with manufacturer-sponsored patient access programs; prior experience at or contracting with major PBMs (ESI/Evernorth, CVS Caremark, OptumRx, Humana Pharmacy Solutions, Prime Therapeutics); familiarity with PSAO contracting structures; working knowledge of CMS Part D pharmacy network regulations and state PBM legislation; experience managing limited distribution network (LDN) contracts or specialty hub-to-pharmacy contracting arrangements. Desired Attributes Has sat across the table from PBM contracting teams and pushed back on terms that eroded pharmacy economics — not intimidated by PBM complexity, and uses it to Gifthealth’s advantage. Maintains productive PBM relationships even when actively negotiating or disputing terms — professionally assertive, not adversarial. Builds internal compliance monitoring systems that catch issues before they become audit findings — proactive, not reactive. Distills complex PBM economics into clear summaries for executive audiences and is comfortable presenting reimbursement performance and contract negotiation strategy at the COO or C-suite level. Builder mentality — excited to put in place the contracts, relationships, and compliance infrastructure that will define Gifthealth’s payer position for years ahead. Work Environment Location: Hybrid Schedule: Full-time. May require travel for industry conferences, PBM partner meetings, and association events. Regular collaboration with pharmacy operations, finance, compliance, technology, and legal. Regular external engagement with PBM contracting, network, and audit teams across all active PBM relationships. Key Essential Functions Must be able to perform sedentary office work for extended periods, including sustained use of a computer and telephone. Must be able to travel for industry conferences, PBM partner meetings, and professional association events. Must be able to communicate effectively verbally and in writing across multiple organizational levels including the C-suite and with external PBM partners. Must be able to manage multiple concurrent PBM contracts, compliance obligations, audit responses, and team responsibilities simultaneously. Employment Classification Status: Full-time FLSA: Exempt Equal Employment Opportunity (EEO) Statement Gifthealth is an Equal Opportunity Employer and prohibits discrimination and harassment of any kind. All employment decisions are made without regard to race, color, religion, sex, sexual orientation, gender identity, transgender status, national origin, age, disability, veteran status, or any other legally protected status. We celebrate diversity and are committed to creating an inclusive environment for all employees. Disclaimer This job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities, duties, or skills required of personnel. Gifthealth reserves the right to modify job duties or descriptions at any time.

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Responsibilities

Lead the full PBM contracting lifecycle, including negotiation of new and renewal agreements and managing primary relationships with PBM partners. Ensure reimbursement integrity, maintain operational compliance, and lead the response to PBM-initiated audits.