Payor and PBM Specialist

Welcome to Clearway Health -At Clearway Health, we’ve been recognized as a Great Place to Work® for four years in a row—and we’re just getting started. We’re redefining specialty pharmacy by improving access to care, delivering personalized support, and helping patients navigate complex medication needs. Our award-winning culture is built on empowering our people to grow, contribute, and make a difference every day. If you’re driven to create meaningful change and thrive in a collaborative, purpose-driven environment, you’ll fit right in. If you’re looking for a role where you can truly make an impact, keep reading below! 

Position Summary:

The Payor & PBM Specialist is a crucial member of our team acting as a liaison between payers, Pharmacy Services Administration Organizations (PSAOs), and Pharmacy Benefit Managers (PBMs)/third-party administrators of prescription drug programs. As a Business Subject Matter Expert, you will lead the efforts in completion and submissions of specialty pharmacy network applications, while helping to evaluate trends and policies and offer solutions. In addition to partnering with cross-functional teams internally, the Payor & PBM Specialist will navigate both the payer and administrator side by cultivating relationships with a strong focus on customer service. The Payor & PBM Specialist will enhance current processes, optimize workflows, and maximize profitability. The Payor & PBM Specialist will lead and manage all aspects of the credentialing and recredentialing processes for the payor agreements and networks. This role ensures compliance with PBM, health plan, accreditation, and regulatory requirements, playing a key role in network access, payer onboarding, and pharmacy readiness. The ideal candidate has in-depth knowledge of application and credentialing standards across PBMs and understands the complex regulatory and operational environment of specialty pharmacy services.

Essential Responsibilities/ Duties:

• Collaborate with Clearway teams and health system partners to address payors, PSAOs and PBMs access challenges, tracking data and troubleshooting with internal and external teams.
• Recommend and educate internal and external partners on submission opportunities and potential solutions.
• Build effective working relationships with national and local payers, PBMs, and PSAOs, ensuring preferred access to their networks through influence and negotiation.
• Attend corporate and site-based committee meetings, as well as other ad hoc meetings with health system personnel, to assess needs, communicate progress on specific projects, and develop relationships.
• Maintain a thorough knowledge of payer policies and industry developments related to specialty pharmaceuticals.
• Design and deploy plans, programs, and processes that optimize workflows and maximize profitability.
• Lead the end-to-end credentialing and recredentialing processes for specialty pharmacies housed within hospital or integrated delivery network (IDN) environments
• Prepare, track, and manage credentialing submissions for major PBMs (e.g. Express Scripts, OptumRx, CVS Caremark) and national, regional, and Medicaid/Medicare Advantage health plans
• Develop and maintain a centralized credentialing database and credential files, ensuring real-time updates and document integrity
• Maintain current knowledge of regulatory and industry changes affecting credentialing and payor enrollment requirements
• Identify process improvements and implement the best practices to streamline credentialing timelines and reduce errors within the organization.

Education:

• Bachelor’s degree or equivalent combination of education/experience

Experience:

• 5 years’ experience in healthcare system setting, ideally with experience in credentialing and PBM application submissions, with at least 2 years specific to health plans.
• 5+ years of experience working in health insurance, healthcare system, or PBM industries is required.

Knowledge and Skills:

• Working knowledge of healthcare payor operations, licensing, provider network participation, and managed care processes.
• Possess strong verbal and written communication skills, suitable for interaction across all organizational levels and external contacts.
• Proficiently use Microsoft Word, Excel, PowerPoint, and Outlook.
• Exhibit the ability to organize and prioritize work effectively to achieve specific deliverables in a fast-paced environment with tight deadlines and competing priorities.
• Ability to influence, build and maintain effective relationships with critical external partners and payors which ultimately impact the business.
• Ability to interpret and apply multi-state regulation and credentialing requirements
• Proficiency in Microsoft Office suite
• Ability to manage confidential and sensitive information with discretion

Additional Knowledge and Skills Preferred:

• Pharmacy industry experience is highly desired.
• Familiarity with CAQH ProView, NPPES, PECOS, and Medicare/Medicaid enrollment portals a plus

Special Working Conditions (On-call, travel, shift, coverage):

• This position may require domestic travel up to 20%

This information is being provided to promote pay transparency and equal employment opportunities at Clearway Health. The current annual compensation range for this position is $87,000 - $109,000. The actual rate within this range that you will be offered will depend on a variety of factors including geography, skills and abilities, education, experience and other relevant factors. In addition to a competitive base salary, this role is eligible to participate in the company’s bonus program as part of its comprehensive and rewarding benefits package. This opportunity offers a compelling combination of compensation and performance-based incentives designed to recognize and reward contributions.

The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required. External and internal applicants, as well as position incumbents who become disabled as defined under the Americans with Disabilities Act, must be able to perform the essential job functions (as listed) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case-by-case basis.