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Pharmacy Contract Specialist

Company name
Tufts Health Plan

Watertown, MA

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Under the direction of the Manager, Pharmacy Contracting, the Pharmacy Contract Specialist is responsible for the negotiation and management of the Specialty Pharmacy agreements, pharmacy related vendor agreements, and home infusion network across all lines of business. Key activities include primary liaison and point of contact for complex provider network as it relates to the interpretation of the contract language, financial terms and all operational aspects of contract management. Other primary activities include monitoring of new to market specialty drugs, determination of network needs, evaluation and of prospective providers, contract negotiation and administration functions across all business lines.

Contracted Provider Set-up/Maintenance and Contract Negotiations

* Set-up and credential contracted Home Infusion and Specialty Pharmacy providers in the Commercial TAHP and Medicare Advantage, Diamond claims systems. Resposible for all demographic (Tax id, NPI, address changes) and operational implementation for complex provider network. Maintain fee schedules with Commercial and Medicare Advantage Provider Reimbursement team and conducts audits for accuracy.

* Draft contract amendments and supporting documentation for all business lines. Work closely with legal department to ensure contract provisions are consistent across providers and ensure all applicable legal terms are included in the signed contract.

* Ability to understand and interpret all aspects of assigned contracts, including financial, legal, and operational with emphasis on implementation of contract terms.

* Lead and/or participate in cross functional meetings as required, lead internal ad hoc groups to address contracting or operational issues.

* Develop and maintain industry standard knowledge and be able to represent the Pharmacy Contracting team within various levels of Tufts Health Plan leadership, and be able to represent the Pharmacy Contracting team in external provider discussions as well.

Lead and or participate in contract negotiations with assigned providers and support the Manager, Pharmacy Contracting in all provider network and vendor related negotiations and discussions

Monitoring and Tracking of Drugs

* Monitor and track new to market SP drugs added to Specialty Pharmacy agreements, requesting access and pricing from SP networks based on therapeutic category, support the Manager Pharmacy Contracting and Clinical Pharmacy team on SP initiatives. Look for administrative efficiencies to improve current internal work flows where appropriate.

* Accurately submit coding requests to Pharmacy Operations Team.

* Maintain fee schedules for home infusion, specialty infusion, submit fee schedule updates for TMP, Commercial, Public Plans and Novalogix pricing vendor.

Track drugs for Model Audit per internal audit requirements.

Support Specialty Pharmacy Management Team

* Key contributor in the quarterly and monthly meetings held with pharmacies, vendors and internal stakeholder meetings including the Quarterly Specialty Dashboard and Pipeline meeting. Run and manage internal and external meetings in absence of Pharmacy Contracting Manager.

* Develop and maintain key relationships with various vendor and provider counterparts.

* Oversee and manage potential assimilation of future complex Public Plan agreements (e.g. Home Infusion and Novalogix) under the Pharmacy Contracting Team.

Support the development and implementation of Specialty Pharmacy strategy as part of the Pharmacy Contracting Team.

* Management of the Novalogix claims management vendor agreement which includes all aspects of vendor management including invoicing. Performance management and primary point of contact for any operational issues.

* Negotiate and administrate out of plan letters of agreement with non-contracted pharmacy and home infusion providers for drugs and other services not available within the contracted network.

* Track and formally respond to ongoing requests from pharmacies and providers seeking to join the THP network.Support department initiatives and projects as indicated.

EDUCATION: (Minimum education & certifications required)* B.S. /B.A. degree required. Master's degree preferred.

EXPERIENCE: (Years of experience)

Minimum of five (5) years of administrative or business experience with two (2) years of experience in health care or health insurance industry preferred.

* Proficient in MS Office-Excel, Word, , and PowerPoint required. Microsoft Access preferred.

* Software/Database experience-THP systems such as MedHOK, RxClaims, CCMS, CAS, Trizetto and Medical Claims systems Reflections (SYSA, Diamond, Redbrick, Forest & Trees and Cognos) or other database/software experience is preferred

SKILL REQUIREMENTS: (Include interpersonal skills)

Excellent analytical skills necessary to interpret pharmacy data and reports and to prepare summary documents for distribution and presentation to both internal and external stakeholders. Requires a high degree of initiative to anticipate the data needs of the department and to research available data sources. Must have excellent oral and written communication skills, including preparation of presentation-ready materials.

Proven time management and organizational skills. Ability to manage multiple tasks, workflows and responsibilities that can vary significantly across business lines and capable of working in a fast paced environment while maintaining accuracy in all elements of the position.

Must be able to work both independently with the ability to identify, understand, research and solve unique and complex financial and operational provider issues as it relates to their contracts and that can vary based on the specific business line. Excellent interpersonal skills required with a high level of diplomacy to recognize and respond to politically sensitive issues.

Work effectively as an integral member of the Specialty Pharmacy Management team.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: (include special requirements, e.g., lifting, travel, overtime)

Fast paced office environment handling multiple demands. Must be able to exercise appropriate judgment as necessary. Open cubicle work setting with a personal computer.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Company info

Tufts Health Plan
Website :

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