Director of PBM Contracting

Description

We are seeking a Director of PBM Contracting to join our Gifthealth team. Reporting to the Chief Legal Officer, this role serves as Gifthealth’s primary point of contact with all PBM partners and owns the full PBM contracting lifecycle, including negotiation of new and renewal agreements, reimbursement integrity and rate validation, compliance monitoring, and audit response. This position plays a key role in Payer Relations / Revenue Operations
, ensuring alignment with organizational goals, operational excellence, and compliance standards.

Gifthealth’s direct-to-patient model operates across multiple payer networks, and the terms we hold with our PBM partners directly shape our reimbursement rates, network eligibility, and compliance posture. The Director of PBM Contracting will build and lead a small team, work cross-functionally with pharmacy operations, finance, compliance, and technology, and ensure our PBM relationships are both commercially optimized and operationally sound.

• PBM Contract Negotiation: Lead all PBM contract negotiations on behalf of Gifthealth, including new network agreements, renewals, amendments, and specialty contract structures. Develop negotiation strategies that optimize reimbursement rates, MAC appeals rights, network access terms, dispensing fee structures, and audit provisions. Own the full contract lifecycle from initial terms through execution and ongoing performance monitoring.
• Primary PBM Relationship Ownership: Serve as Gifthealth’s named point of contact with all PBM partners, including commercial, Medicare Part D, Medicaid managed care, and specialty PBMs. Build and maintain active working relationships with PBM contracting, network, and compliance teams. Represent Gifthealth professionally and authoritatively in every PBM interaction.
• Reimbursement Integrity and Rate Validation: Own the process for validating that Gifthealth is receiving accurate reimbursements consistent with contracted terms across all PBM networks. Monitor adjudication data for rate anomalies, underpayments, and clawback patterns. Coordinate with pharmacy operations and finance to resolve discrepancies and recover owed reimbursements.
• PBM Compliance Management: Ensure Gifthealth’s operations remain in continuous compliance with PBM network agreements, provider manuals, credentialing requirements, and performance standards. Monitor for contract amendments or policy updates from PBM partners and translate requirements into internal operational actions with appropriate lead time.
• Audit Support and Response: Serve as Gifthealth’s lead for PBM-initiated audits, coordinating evidence collection, preparing response documentation, communicating with PBM audit teams, and managing remediation. Work proactively to reduce audit risk through internal controls, documentation standards, and pre-audit readiness reviews.
• Team Leadership: Build and lead a team of PBM Contracting Specialists and Analysts. Assign and manage workload across the PBM portfolio, develop team expertise in contract analysis and payer relations, and create internal processes and tools that scale with Gifthealth’s growing network of PBM relationships.
• Continuing Education and Market Intelligence: Maintain an active continuing education posture across PBM contracting, reimbursement policy, pharmacy network legislation, and CMS guidance. Attend industry conferences, participate in pharmacy association forums, and leverage PBM partner relationships to stay ahead of changes that affect Gifthealth’s contract terms or compliance obligations.
• Cross-Functional Collaboration: Partner with pharmacy operations on network credentialing and compliance execution; with finance on reimbursement forecasting and per-dispense economics modeling; with technology on claims and adjudication data infrastructure; and with compliance and legal on contract review and regulatory interpretation.

• Education: Bachelor’s degree or equivalent experience required; degree in healthcare administration, pharmacy, business, or a related field preferred.
• Experience: 8+ years of experience in PBM contracting, payer…