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 payors, 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, you will navigate both the payor and administrator side by cultivating relationships with a strong focus on customer service. The Specialist enhances 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, payor 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 payor, 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 payors, 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 payor 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 credentialing and PBM application submissions, with at least 2 specifics to PBMs and health plans
• Pharmacy industry experience is highly desired.

Knowledge and Skills:

• Working knowledge of specialty pharmacy operations, licensing, and payer network participation
• Familiarity with CAQH ProView, NPPES, PECOS, and Medicare/Medicaid enrollment portals a plus
• Strong attention to detail and data accuracy
• Ability to manage multiple reporting deadlines and priorities
• Excellent communication skills with internal and external stakeholders
• Problem-solving mindset with a focus on continuous improvement

Special Working Conditions (On-call, Travel, Shift, Coverage):

• Travel up to 20% annually

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.

Originally posted on Himalayas