Formulary Operations Pharmacist – Medicare

Position Summary:

The Formulary Operations Pharmacist – Medicare is responsible for providing operational support for the evaluation, implementation, and maintenance of Medicare Part D formularies and utilization management. This individual supports creation and maintenance of formulary and utilization management lists, preparation of CMS formulary files and member formulary drug lists, preparation and review of updates for implementation, and other formulary and utilization management related tasks and processes. The role requires strong cross functional collaboration and communication skills, and an understanding of Medicare Part D formulary management processes and related CMS rules and regulations.

Position Responsibilities:

Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelines

Support development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug lists

Lead and support preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, andutilization management criteria

Evaluate drugs/drug classes, make formulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalize

Evaluate appropriateness of and operationalize custom client formulary and benefit change requests within the formulary and adjudication platform

Support comprehensive testing of client formulary and benefit elections

Provide cross functional support for claim troubleshooting within the adjudication platform

Monitor and analyze regulatory and legislative requirements for Medicare

Support development of project plans to meet new CMS requirements, and support cross functional teams with implementation of programs to meet requirements

Lead formulary change processes within URAC/NCQA/CMS guidelines

Pharmacy and Therapeutics (P&T) Committee participation as an ad hoc member

Conduct formulary reviews and develop drug monographs based on a rotation of clinical pharmacists

Maintain and update the Capital Rx pharmaceutical pipeline, as needed

Develop clinical criteria for review as needed

Support CMS formulary administration audits

Support quality improvement projects as needed

Support Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed

Support general business needs and operations, as needed

Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Minimum Qualifications:

Doctor of Pharmacy (PharmD) Degree from an accredited institution, with record of strong academic performance

Current, unrestricted registered pharmacist license(s)

Residency/fellowship preferred

2-3 years of formulary experience working for a health plan or PBM preferred

2-3 years of Medicare experience preferred

Knowledge of formulary development and maintenance processes

Knowledge of highly managed specialty medications/strategy

Knowledge of rebate and financial implications of formulary strategies

Experience working with large datasets preferred

Ability to independently identify, research, and resolve issues

Ability to balance multiple complex projects simultaneously

Ability to work extended hours, weekends, and holidays consistent with industry demands

Exceptional written and verbal communication skills

Extremely flexible, highly organized, and able to shift priorities easily

Attention to detail & commitment to delivering high quality work product

Microsoft office suite with emphasis on Microsoft excel proficiency required

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

Salary Range

$125,000 - $135,000 USD

About Capital Rx

Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi®, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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