Department: Gateway Health Partners / Network Management
Reports To: SVP, Product & Strategy
FLSA Status: Exempt
Education: Bachelor's degree
Experience: Experience in Analytics including large data sets, MAC modeling, and process automation
KNOWLEDGE, SKILLS, AND ABILITIES
- Excellent management and planning skills, detail oriented. Strong analytical and problem solving skills. Ability to organize and manage multiple priority tasks simultaneously. Proven and demonstrated project management skills, directing project activities to a cross-functional team
- Problem solving ability in unstructured situations. Ability to lead effective meetings, accomplish goals and meet timelines. Ability to work well in cross-functional situations, giving clear direction and partnering with other internal departments to reach common goals
- Ability to manage, mentor, and develop team members with expertise on MAC pricing and the adjudication systems with particular emphasis on developing processes that are both accurate and efficient
- Experience influencing change and adoption of new analytic capabilities to support pricing financial analytics
- Experienced user of two or more of the following: SQL, SAS, Alteryx, Tableaa, Power BI, R, or Python technologies
- May represent GHP/Network Management department on cross-functional projects or initiatives
The Manager of Network Pricing & MAC is responsible for network pricing strategy as well as the execution, implementation, and optimization of current, new, and future network / pricing innovation. Will lead complex financial modeling and process development to create business insight, quality assurance, and execution to achieve departmental goals.
In partnership with other team leaders and members, develop reimbursement strategy, execute on network pricing, and oversee pharmacy analytics including activities that fall under the MAC Management umbrella.
Develop capabilities specifically targeted to achieve the efficient and effective application of the company's products and services toward the achievement of total cost savings and improved health outcomes for the company's clients and their members.
(These duties must be performed with or without reasonable accommodation. This document in no way states or implies that these are the only duties to be performed by the employee occupying this position)
- Develop business, industry, competitive, client, and technical knowledge to formulate pricing strategy, and to execute financial modeling of comprehensive pricing strategies
- Consult with internal leaders and departments to coordinate relevant cross functional activities in support of network performance management efforts to maximize the organization's competitive position
- Collaborate with the Underwriting team to provide recommendations on pricing and negotiation strategy to achieve revenue, profitability targets, and margin retention, for new and existing customers
- Execute and implement dynamic pricing strategies in response to market fluctuations to provide competitive, profitable, and best of class pricing offers
- Establish, maintain, and adjust as necessary a MAC pricing algorithm in coordination with company strategy, contractual financial obligations, market conditions, and adherence to state MAC laws
- Develop understanding of claim adjudication pricing parameters and lead process development to automate network / MAC builds and pricing adjustments while incorporating QA validation
- Develop and maintain MAC reference file to track and support MAC setups inquires
- Build and maintain claim re-pricing process that forecasts Pharmacy, Client, and Member pricing impact
- Identify gaps in current processes and provide / implement recommendation to streamline efficiencies and quality
- Utilize and maintain domain expertise across levers of PBM financials, including retail networks, dispensing, specialty drugs, pharmaceutical manufacturer rebates, MAC pricing, and our product offerings
- Proven ability to collaborate effectively with a cross-functional team to align and coordinate internal resources. In addition, coach, lead, mentor and assist with staff career development
- Proactive identification and closure of network gaps as well as development of performance reports
- Promptly report any allegations of impropriety to the Compliance Department
- Comply with Gateway's Ethical Business Conduct policy and Gateway's Compliance Program
- Remain free from exclusion under the OIG and SAMS Medicare/Medicaid lists
- Complete required training, as assigned, within the established timeframes
- Must be able to cope with the mental and emotional stress of the position
- Perform other job-related duties as assigned
(With or without the aid of mechanical devices)
- Must be able to move intermittently throughout the day
- Must be able to speak the English language in an understandable manner
- Must possess the sight/hearing senses, or use prosthetics that will enable these senses to function adequately, so that the requirements of this position can be fully met
- Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other staff
- Must be in good general health and demonstrate emotional stability
- Must be able to operate office, business, and accounting machines
- Sitting, standing, bending, lifting, and moving intermittently during working hours
- Works in well lighted/ventilated office areas
- Subject to frequent interruptions
- Willingness to work beyond normal working hours, and in other positions temporarily, when necessary
- Attend and participate in continuing educational programs
- Communicates with both external and internal customers
We are transforming the pharmacy industry to create healthier lives through purposeful engagement across Pharmacy Benefit Management, Pharmacy Management, Specialty Pharmacy, 340B, Rebate and Formulary Management, and Pharmacies. We put people first and are committed to providing outstanding service across all aspects of our business. Our goal is to create flexible and innovative solutions filled with inspired possibilities.
Our team brings robust experience, diverse perspectives and passion from a nationwide team of 900+ professionals located in more than half of the US states.
WHY JOIN OUR TEAM?
Gateway offers a progressive culture that supports a work from home model, a "dress for your day" attire, and a collaborative, team oriented environment. We offer a comprehensive compensation & benefits package including:
- $750 individual, annual medical deductible, $25 office visit copays
- Low biweekly premiums
- Company paid basic life/AD&D, Short-term and Long-term disability insurance
- Rx, dental, vision, short-term disability, and FSA
- Employer-matched 401k Plan
- And more!
The innovative spirit at Gateway will transform the way you think about pharmacy & healthcare services. As we pave the way in a relentless commitment to positive health outcomes, it's never been a better time to be part of our team!
Gateway is an EEO / AA / M / F / Vets / Disability