Manager, Payor Operations And Solutions

Manager, Payor Operations And Solutions

Responsible for leading and directing activities associated with the operations, implementation, and maintenance of executed contracts for third-party programs. Works cross-functionally to coordinate contract administration for pharmacy and medical benefit programs including processing, billing, reimbursement, formulary, and payment information. Ensures that policies and procedures are revised and implemented to address any operational issues identified on the Walgreens side. Knowledge and understanding of products and services, store/field operations, and contracts as well as knowledge of the managed care and insurance industries and their respective business issues and potential opportunities.

Job Responsibilities:

• Partners with the management team to identify, develop, and implement appropriate approaches, processes, and tools that elevate the analytics group.
• Monitors the contract terms and commitments to assure all deliverables are adhered to and take proactive measures before key milestones are missed.
• Monitors the implementation process for all third-party programs, while balancing client needs and company objectives to ensure a successful/positive implementation for both parties.
• Ensures maximum gross sales and profit by working closely with Contracting Directors/Managers through the ongoing review and confirmation of any non-standard third party plan setup requests.
• Works with corporate and field on any reimbursement issues, and brings exceptions or non-standard requests to the attention of senior management where appropriate.
• Maintains communication regarding third party participation, contract compliance, and any other operational issues or opportunities.
• Manages the tracking, approval, administration, and post-implementation process of all Managed Care contracts throughout the contract life cycle.
• Works with Contracting Directors/Managers to review Third Party Managed Care Contracts to ensure operational requirements can be met and implemented.
• Monitors the technical links between the Third Party Provider and data tracking systems to assure reported issues are properly captured, reported, prioritized, and managed to closure.
• Oversees a Third Party Governance Process including periodic status calls, quarterly performance reviews, annual business planning, change order reviews, and Third Party budgets/costs.
• Conducts periodic meetings/calls with internal departments to address administration issues, and coordinates resolution with the Service Provider as required.
• Trains and provides ongoing education to personnel, customers, contractors, etc. on processes and procedures to address Payor related issues, updates, and opportunities.
• Works with appropriate internal and external parties to load and update new/existing location, market, and provider information.
• Manages and audits the loading and updates of pricing and reimbursement terms to ensure contract compliance and appropriate profit and reimbursement.
• Creates and oversees the training schedule of new employees as well as participate in a significant amount of training for new and existing employees. Provides analytical guidance, mentoring, and coaching to the team and peers.

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