General Description of the Job Class:
Has primary responsibility for identifying prospective managed care contracts, negotiation, and rate determination for the Duke University Health System, Inc. retail pharmacies. Oversee the data collection function using pharmacy specific analytic tools to effective manage the pharmacy agreements. Ensure compliance with quality and reimbursement expectations in our pharmacy agreements with government and private payers. Interacts closely with various Duke University Health System retail pharmacies to maximize operational efficiency in the administration and revenue maximization of all managed care contracts.
Duties and Responsibilities
Responsible for the development and management of negotiations for managed care contracts in a manner consistent with the Health System’s strategic approach to managed care, including:
- Evaluation of new contracting opportunities, including substantive and pricing components, for the Health System.
- Management of financial, operational, and legal analysis of proposed pharmacy benefit management agreements.
- Serve as the primary negotiator in pharmacy managed care negotiations. Negotiates contract rates and language provisions in accordance with established DUHS policy and procedure.
- Assist in the development of the necessary systems to support the data and analysis needs of DUHS Managed Care, Retail Pharmacies and DUHS Corporate Finance.
- Responsible for assisting in the implementation of managed care contracts, including:
- Coordinate with Patient Revenue Management Organization the contract implementation process for appropriate internal audiences, including hospital and professional administrative and professional staffs.
- Identify and recommend appropriate changes in operating procedures and systems that might be required to accommodate a managed care contract.
- Interacts closely with various Duke University Health System components to maximize operational efficiency in the administration and revenue maximization of all managed care contracts.
- Maintain full understanding of the retail pharmacy operations, responds to payer audits and proactively monitors retail pharmacies compliance with payer contract requirements.
- Manage the pharmacy specific analytic software tools – RxPA
- Acts as main user for the RxPA web tool
- Train as super user for RxPA web tool and act as the liaison between pharmacies and vendor
- Perform in-depth analysis and reimbursement exceptions management, including but not limited to, MAC appeals, reimbursement monitoring, cost analysis, etc.
- Attend RxPA conference calls/business reviews regularly and follow-up on recommendations/best practices
- Proactively reviews for denied claims and seeks and advises for contracting opportunities
- Monitor the performance of pharmacy benefit management agreements, including:
- Development and maintenance of quarterly management reports for Health System senior management analyzing activities, trends, costs and profitability.
- Monitor managed care companies’ compliance with contractual requirements of the managed care agreements. Responds quickly and effectively to negative trends.
- Evaluate existing agreements and report findings/recommendations to renegotiate/modify/terminate contractual relationships to DUHS Managed Care.
- Meet with plan representatives to discuss ways to strengthen existing relations.
- Responsible for representing the Health System to external audiences at conferences, presentations, workshops, association meetings, community events, etc., including:
- Represent the Health System to managed care entities in day-to-day customer service relations.
- Performs other assigned responsibilities and projects as delegated by the Senior Director, Managed Care.
- Develops and implements a personal development program to ensure continuing professional growth.
Knowledge, Skills, and Abilities:
- Excellent direct negotiation, analytical, verbal and written communication skills.
- Ability to prioritize, works well independently, and handles multiple projects simultaneously.
- Direct experience with financial analysis and contract analysis highly desirable.
- Must be knowledgeable regarding health care, managed care concepts, third party payer contract terms and legal issues, financial analysis, and the medical reimbursement environment.
- The position must be able to facilitate and problem solve at multiple levels within the organization.
- The position must be able to appropriately represent the organization to external audiences.
- Experience with IBM-PC software packages (Lotus Notes, Word, Excel, and Access).
Duke Entity HEALTH SYSTEM
Job Family Level E2
Full Time / Part Time FULL TIME
Regular / Temporary Regular
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions:
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
Bachelor's degree in Accounting, Economics or a related business field
Work generally requires 1 year of experience
Degrees, Licensures, Certifications