Network Specialist

Summary

Managed Health Care Associates, Inc. provides access, solutions, and insights to care communities to help them operate more effectively. The Network Specialist serves as a subject matter expert for the LTC Network, overseeing claims and reimbursement matters, supporting strategic member accounts, managing network operations, and communicating insights and solutions to stakeholders.

Responsibilities

• Research and resolve payment discrepancies, reimbursement issues, claims exceptions, and network participation concerns
• Analyze claims, reimbursement, and operational data to identify trends, anomalies, and complex operational issues
• Partner with member pharmacies, PBMs, payers, Net-Rx or comparable platform partners, and internal teams to investigate and resolve reimbursement matters
• Escalate issues appropriately and communicate findings, recommended next steps, and resolutions to relevant stakeholders
• Manage assigned strategic member accounts and provide responsive, proactive support in partnership with Account Executives and internal stakeholders
• Support Account Executives with member inquiries, operational challenges, and reimbursement-related concerns
• Participate in member business reviews, regional meetings, and other member-facing discussions; prepare and present content highlighting Network value, performance, updates, and offerings
• Build and maintain strong relationships with member pharmacies and key stakeholders to support member satisfaction and retention
• Provide subject matter expertise regarding payer contracts, pharmacy reimbursement methodologies, Medicare Part D, Medicaid, managed care, network participation, claims processing, enrollment, and eligibility
• Coordinate with LTC Network Operations on payer contract retrieval and review, payer and pharmacy compliance, credentialing requirements, enrollment, information changes, and escalated or high-profile member issues
• Manage pharmacy LTC Network enrollment activities, demographic and information changes, payer information, credentialing, and compliance requirements
• Identify opportunities for member pharmacies to use additional MHA Network Services and support data-informed discussions regarding Network value
• Develop and maintain monthly reports, dashboards, reporting summaries, and operational analyses
• Evaluate claims and operational data for accuracy and consistency, identify discrepancies, and coordinate appropriate follow-up
• Prepare and distribute network communications, FAQs, training materials, process documentation, and other member-facing or operational resources
• Communicate network updates, reporting insights, and complex information clearly to technical and non-technical audiences
• Utilize approved AI, automation, reporting, and productivity tools to improve operational efficiency, support data analysis, enhance reporting capabilities, and streamline member and stakeholder communications
• Identify operational inefficiencies, recommend improvements, and support implementation of solutions that improve data accuracy, member experience, and operational effectiveness
• Collaborate with Sales, Account Management, Operations, Finance, and other business partners to address members’ needs and improve outcomes
• Manage multiple member requests, projects, priorities, and deadlines while balancing member needs with contractual and operational requirements
• Maintain awareness of day-to-day Network activities, member needs, payer developments, and industry trends to support timely communication and issue resolution

Skills

• * Working knowledge of pharmacy reimbursement methodologies, payer networks, Medicare Part D, Medicaid, managed care, enrollment, eligibility, claims processing, and payer or pharmacy contracting
• * Understanding of pharmacy network operations, contracting, and member support processes
• * Strong analytical and reporting skills, including the ability to identify trends, discrepancies, anomalies, and operational issues within claims and operational data
• * Proficiency in Microsoft Office products, including strong Excel skills; experience with reporting tools and databases preferred
• * Ability to interpret data and translate findings into clear, actionable recommendations
• * Leverages approved AI, automation, and data analysis tools to identify trends, research reimbursement and claims issues, develop reporting insights, improve operational effectiveness, and support informed business decisions while maintaining data integrity and confidentiality
• * Ability to build strong working relationships with member pharmacies, Account Executives, PBMs, payers, and internal business partners
• * Strong customer service orientation with a proactive, responsive approach to member needs and issue resolution
• * Ability to balance member needs with contractual and operational requirements
• * Excellent verbal, written, presentation, and customer service skills, including the ability to explain complex information clearly to technical and non-technical audiences
• * Demonstrated ability to collaborate effectively across departments and work independently when researching and resolving issues
• * Strong organizational and project management skills, attention to detail, and ability to manage multiple priorities and deadlines
• * One or more years of experience in PBM account management, pharmacy network contracting, claims, reimbursement, managed care, or equivalent client-facing healthcare experience
• * Ability to travel 25-50% of the time
• * Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; sit; perform manual tasks; operate tools and other office equipment such as computers, computer peripherals and telephones; extend arms; kneel; talk and listen
• * Mental Demands:The employee must be able to follow directions, to get along with others, and handle stress
• * Long-term care pharmacy experience preferred
• * Proficiency in Microsoft Office products, including strong Excel skills; experience with reporting tools and databases preferred
• * Experience with Net-Rx or a comparable pharmacy, healthcare, claims, or reimbursement platform preferred
• * Experience developing reports, member-facing communications, FAQs, training materials, process documentation, and operational resources preferred
• * Bachelor's degree preferred
• * Experience in using Salesforce or a comparable customer relationship management platform for reporting and activity management preferred

Qualifications

Must Haves

• * Working knowledge of pharmacy reimbursement methodologies, payer networks, Medicare Part D, Medicaid, managed care, enrollment, eligibility, claims processing, and payer or pharmacy contracting
• * Understanding of pharmacy network operations, contracting, and member support processes
• * Strong analytical and reporting skills, including the ability to identify trends, discrepancies, anomalies, and operational issues within claims and operational data
• * Proficiency in Microsoft Office products, including strong Excel skills; experience with reporting tools and databases preferred
• * Ability to interpret data and translate findings into clear, actionable recommendations
• * Leverages approved AI, automation, and data analysis tools to identify trends, research reimbursement and claims issues, develop reporting insights, improve operational effectiveness, and support informed business decisions while maintaining data integrity and confidentiality
• * Ability to build strong working relationships with member pharmacies, Account Executives, PBMs, payers, and internal business partners
• * Strong customer service orientation with a proactive, responsive approach to member needs and issue resolution
• * Ability to balance member needs with contractual and operational requirements
• * Excellent verbal, written, presentation, and customer service skills, including the ability to explain complex information clearly to technical and non-technical audiences
• * Demonstrated ability to collaborate effectively across departments and work independently when researching and resolving issues
• * Strong organizational and project management skills, attention to detail, and ability to manage multiple priorities and deadlines
• * One or more years of experience in PBM account management, pharmacy network contracting, claims, reimbursement, managed care, or equivalent client-facing healthcare experience
• * Ability to travel 25-50% of the time
• * Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; sit; perform manual tasks; operate tools and other office equipment such as computers, computer peripherals and telephones; extend arms; kneel; talk and listen
• * Mental Demands:The employee must be able to follow directions, to get along with others, and handle stress

Nice to Haves

• * Long-term care pharmacy experience preferred
• * Proficiency in Microsoft Office products, including strong Excel skills; experience with reporting tools and databases preferred
• * Experience with Net-Rx or a comparable pharmacy, healthcare, claims, or reimbursement platform preferred
• * Experience developing reports, member-facing communications, FAQs, training materials, process documentation, and operational resources preferred
• * Bachelor's degree preferred
• * Experience in using Salesforce or a comparable customer relationship management platform for reporting and activity management preferred

Benefits

• Comprehensive medical, dental, and vision plans with FSA/HSA options
• Fitness reimbursement
• Access to an Employee Assistance Program
• Paid time off, holidays, personal days, paid parental leave, plus your Birthday as a day off!
• Life Insurance, short-term & long-term disability insurance
• 401K match
• Employee Stock Purchase Plan
• Voluntary financial and legal benefits, through our benefits providers
• E-learning programs
• Tuition Reimbursement
• Ongoing Team Trainings
• Paid volunteer time-off
• Donation matching