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Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Network Management Specialist will assist in building and maintaining high-performance provider networks by identifying opportunities to contract with providers and improve the contractual performance. Works closely with other departments to enhance the contracted provider experience consistent with company's mission statement and values.

(May include but are not limited to)

• Recruits new providers.
• Prepares supporting documentation, negotiates and implements contracts for physicians and ancillary providers for existing and developing markets.
• Acts as technical resource on provider relations issues. Responsible for timely and professional interaction with internal and external customers.
• Utilizes understanding of the business risk relationships to interact and influence key physician leaders.
• Maintains internal awareness of network changes by issuing timely and accurate provider update communications about contractual risk disposition changes, provider terminations and additions, and panel closures.
• Ensures overall compliance by responding to grievances/appeals and adhering to regulatory and departmental Policy and Procedure guidelines and timeframes.
• Maintains up-to-date, accurate provider database by overseeing proofing effort, prompt processing of terminations and/or provider changes.
• Supports department efforts and Network Management by participating in interdepartmental meetings and selected committees.
• Contributes to team effort by accomplishing related results as needed.

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Minimum 5+ years' experience in provider relations/contracting with an HMO or IPA, medical group or institutional provider required.

• Bachelor's Degree preferred.

• Knowledgeable of reimbursement structures for physicians and ancillary providers.
• Knowledgeable about Medicare guidelines
• Strong analytic, quantitative, and problem-solving skills required.
• Strong verbal and written communication skills required.
• Strong presentation skills and ability to appropriately and effectively address diverse audiences required.
• Proficiency in MS Word and Excel required; Access database proficiency preferred.

• Office Hours: Monday-Friday, 8am to 5pm. Extended work hours, as needed.
• 20% travel may be required at times.

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Our work matters. We help people get the medicine they need to feel better and live well. It fuels our passion and drives every decision we make. The Network Management Consultant is responsible for the development, performance and management of Prime's retail, mail, specialty, and quality-based networks aligning with Prime's Supply Chain Cost of Goods Sold (COGS) and network management strategies. This includes development of network contracts, participation requirements, analysis of pharmacies, and ensuring contract and regulatory compliance. This position is accountable for creation and management of specialty fee schedules to ensure competitiveness and serves as the liaison between Prime's Network Management and Specialty teams.

Responsibilities include: negotiating market competitive high-profile and/or complex pharmacy agreements across all channels including retail, mail, specialty and quality based and lines of business aligning with Supply Chain COGS strategies; leading and managing specialty fee schedule development process and ensuring fee schedule revisions align with Supply Chains COGS strategies for specialty drug management; leading and implementing network initiatives by facilitating and performing network analyses, contracting activities and fee schedule development aligning with strategy, priorities and project goals; partnering with Prime's reporting and analytics teams to develop network vendor loading rules inclusive of approved preferred and specialty pharmacies; maintaining key compliance criteria and implementing quarterly reporting processes for all contracted network specialty pharmacies; analyzing network specialty pharmacy quarterly reports to ensure compliance with reporting and participation requirements; collaborating with Specialty Clinical Program Directors to identify potential performance gaps; working with internal and external partners to develop and manage corrective action plans; managing the pharmacy contract from negotiation of all terms, ensuring Prime and Pharmacy compliance and document retention aligning with Prime's Record Information Management (RIM) policies; working closely with Prime's legal team to update contract documents including agreements and applications for utilization in contracting/re-contracting activities based on new network participation requirements; and other duties as assigned.

Bachelor's degree in business or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required. 8 years of Network Management experience within Pharmacy Benefit Management (PBM), healthcare or other highly regulated industry; including 5 years of managed care experience in medical or pharmacy network contracting. Must be eligible to work in the United States without need for work visa or residency sponsorship.

Excellent verbal and written presentation skills. Demonstrated understanding of network reporting and analysis for specialty pharmacy. Demonstrated ability to establish trust and credibility; form working relationships with all levels of an organization. Demonstrated ability to work independently and on highly complex contract language and agreements; strong attention to detail. Enhanced organizational skills with the ability to work on multiple projects simultaneously. Demonstrated ability to problem solve and interpret complex data; ability to analyze network information and synthesize it into meaningful information for a variety of audiences. Ability to work with confidential data and maintain privacy.

Master's degree in business, healthcare or related area of study. Demonstrated understanding of retail and specialty network fee schedule management. 2 years of experience in specialty contracting. PBM or Healthcare experience.

Ability to travel up to 15% of the time. Constantly required to sit, use hands to handle or feel, talk and hear. Frequently required to reach with hands and arms. Occasionally required to stand, walk and stoop, kneel, and crouch. Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (pregnancy, sexual orientation, and gender identity), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Our work matters. We help people get the medicine they need to feel better and live well. It fuels our passion and drives every decision we make. The Network Management Consultant is responsible for the development, performance, and management of Prime's retail, mail, specialty, and quality-based networks aligning with Prime's Supply Chain Cost of Goods Sold (COGS) and network management strategies. This includes development of network contracts, participation requirements, analysis of pharmacies, and ensuring contract and regulatory compliance. This position is accountable for creation and management of specialty fee schedules to ensure competitiveness and serves as the liaison between Prime's Network Management and Specialty teams.

Responsibilities include:

• Negotiating market competitive high-profile and/or complex pharmacy agreements across all channels including retail, mail, specialty, and quality based and lines of business aligning with Supply Chain COGS strategies
• Leading and managing specialty fee schedule development process and ensuring fee schedule revisions align with Supply Chains COGS strategies for specialty drug management
• Leading and implementing network initiatives by facilitating and performing network analyses, contracting activities, and fee schedule development aligning with strategy, priorities, and project goals
• Partnering with Prime's reporting and analytics teams to develop network vendor loading rules inclusive of approved preferred and specialty pharmacies; maintaining key compliance criteria and implementing quarterly reporting processes for all contracted network specialty pharmacies
• Analyzing network specialty pharmacy quarterly reports to ensure compliance with reporting and participation requirements; collaborating with Specialty Clinical Program Directors to identify potential performance gaps; working with internal and external partners to develop and manage corrective action plans
• Managing the pharmacy contract from negotiation of all terms, ensuring Prime and Pharmacy compliance and document retention aligning with Prime's Record Information Management (RIM) policies
• Working closely with Prime's legal team to update contract documents including agreements and applications for utilization in contracting/re-contracting activities based on new network participation requirements
• Other duties as assigned

Education & Experience:

• Bachelor's degree in business or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required
• 8 years of Network Management experience within Pharmacy Benefit Management (PBM), healthcare, or other highly regulated industry; including 5 years of managed care experience in medical or pharmacy network contracting
• Must be eligible to work in the United States without need for work visa or residency sponsorship

Additional Qualifications:

• Excellent verbal and written presentation skills
• Demonstrated understanding of network reporting and analysis for specialty pharmacy
• Demonstrated ability to establish trust and credibility; form working relationships with all levels of an organization
• Demonstrated ability to work independently and on highly complex contract language and agreements; strong attention to detail
• Enhanced organizational skills with the ability to work on multiple projects simultaneously
• Demonstrated ability to problem solve and interpret complex data; ability to analyze network information and synthesize it into meaningful information for a variety of audiences
• Ability to work with confidential data and maintain privacy

Preferred Qualifications:

• Master's degree in business, healthcare, or related area of study
• Demonstrated understanding of retail and specialty network fee schedule management
• 2 years of experience in specialty contracting
• PBM or Healthcare experience

Physical Demands:

• Ability to travel up to 15% of the time
• Constantly required to sit, use hands to handle or feel, talk and hear
• Frequently required to reach with hands and arms
• Occasionally required to stand, walk, and stoop, kneel, and crouch
• Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus

Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills.