Specialist, Contract Operations
Contract Operations Governance & System Oversight
The Specialist, Contract Operations leads operational implementation and lifecycle management activities associated with payer contract configurations, reimbursement methodologies, and pricing structures within specialty pharmacy systems. They interpret payer contract requirements and determine appropriate operational and system configuration approaches to support reimbursement accuracy and downstream claims processing integrity. They maintain payer mappings, reimbursement structures, pricing logic, and configuration elements required to support accurate claims adjudication and operational execution. They review, analyze, and resolve complex operational discrepancies, configuration issues, and reimbursement-impacting data integrity concerns. They recommend corrective actions and operational improvements to mitigate reimbursement risk and strengthen configuration accuracy.
Contract Pricing Data Operations & Governance
The Specialist oversees recurring pricing update processes, including monthly, quarterly, and ad hoc pricing maintenance activities across methodologies such as AWP, ASP, WAC, NADAC, and payer-specific fee schedules. They analyze pricing methodologies, reimbursement structures, and operational impacts associated with payer pricing configurations. They retrieve, validate, interpret, and apply pricing data from external reimbursement and pricing sources like Redbook, RJ Health, Medicaid, and Medicare. They exercise operational discretion in validating pricing logic, escalating prioritization, and addressing reimbursement-impacting discrepancies. They ensure pricing updates are accurately implemented across impacted systems and operational workflows.
Contract Operationalization & Cross-Functional Coordination
The Specialist leads operational implementation activities associated with executed payer agreements and reimbursement structures. They partner cross-functionally with Managed Markets, Reimbursement, Operations, Intake, Authorizations, Quality Assurance, Finance, and IT to support operational readiness and implementation alignment. They provide operational guidance and recommendations regarding payer configuration requirements, reimbursement structures, implementation dependencies, and system readiness. They independently prioritize implementation activities based on operational urgency, reimbursement impact, and downstream business dependencies. They support operational decision-making associated with payer onboarding, reimbursement implementation strategy, and operational scalability initiatives.
Operational Governance, Audit Readiness & Risk Mitigation
The Specialist maintains audit-ready documentation supporting payer configurations, pricing updates, reimbursement structures, and operational changes. They ensure all updates and configuration activities remain traceable, version-controlled, and aligned to governance and compliance standards. They evaluate operational workflows, governance controls, and reimbursement processing dependencies to identify opportunities for operational improvement and risk reduction. They identify operational risks, reimbursement-impacting discrepancies, and data integrity concerns requiring escalation or corrective action. They support development and enhancement of governance controls, operational procedures, and scalable workflow standards.
Process Optimization & Continuous Improvement
The Specialist evaluates operational processes and recommends workflow enhancements, automation opportunities, and system optimization initiatives. They participate in operational planning and process improvement initiatives supporting scalability, reimbursement integrity, and operational efficiency. They support implementation of standardized operational frameworks and repeatable control structures across payer and reimbursement operations. They contribute to cross-functional initiatives focused on improving operational accuracy, reducing manual intervention, and strengthening reimbursement outcomes.