Clinical Formulary Pharmacist

SCAN Health Insurance

9d • Hybrid

About The Position

The Clinical Formulary Pharmacist will play an important role in providing operational support for evaluation, implementation, and maintenance of Medicare Part D Formulary and Utilization Management, review of new drugs with the Pharmacy & Therapeutics Subcommittee/Committee. This position is accountable for ensuring regulatory compliance with respect to the Medicare Part D formulary submissions to CMS, pharmacy benefits, formulary and transition program implementation with PBM, website content for all business lines, pharmacy ne work and CMS’s Part D regulatory audits. The Clinical Formulary Pharmacist stays abreast of pharmacy, PBM, payer industry changes, pipeline, drug trends, best practices, and CMS’s rules and regulations, including Inflation Reduction Act. The role requires strong cross functional collaboration and communication skills, and an understanding of Medicate Part D formulary and Utilization Management (UM) processes.

Requirements

• 3-5 years of related experience
• Bachelor’s Degree required, Pharm D Required
• Pharmacists (PHs) Registered Pharmacy Licensure required within 6 months of hire
• Managed care experience at the PBM, health plan or medical group, required.
• Medicare Part D experience in formulary management, required.
• Excellent verbal/written communication, interpersonal, presentation, customer, problem-solving and computer skills, required.
• Effective utilization of information systems required.
• Technical skills: Microsoft Office (Word, Excel, PowerPoint, Outlook, Teams) - required.

Nice To Haves

• Residency Program in Managed Care, Pharmacy Practice, Drug Information or Geriatric Pharmacy preferred.
• SQL, Tableau, and/or Alteryx - preferred

Responsibilities

• Ensures regulatory compliance with P&T operations, Formulary & Benefit Administration, Transition Programs, annual Part D bid submission process, pharmacy-related member and other stakeholders’ communications and marketing materials, including member formulary drug list, website content, trainings, pharmacy network and CMS’s regulatory audits.
• Produces, maintains, and implements Part D Formulary, Prior Authorization criteria, Step Therapy criteria, Supplemental files, and clinical rules in accordance with CMS requirements on monthly and annual basis and submits these files to CMS.
• Develops and maintains formulary exception criteria.
• Evaluates and reviews new drugs/biosimilar with the Pharmacy & Therapeutics Subcommittee/Committee within 90-180 days of being marketed and makes Formulary and UM recommendations based on the clinical appropriateness, cost analysis and CMS guidelines.
• Works in collaboration with Medical Directors to evaluate and analyze treatment protocols and procedures related to the SCAN Health Plan formulary, at least annually.
• Provides CMS Part D regulatory audit support for respective areas.
• Produces member communications and marketing materials, within internally determined timeframes, with accuracy and in accordance with CMS marketing guidelines. Partners with Marketing, Compliance and Member Services and vendors, as needed.
• Prepares training materials.
• Maintains on-line comprehensive formulary on a monthly basis on accordance with CMS requirements.
• Assists with Formulary and UM modeling for the annual Formulary and BID submissions to CMS.
• Reviews accuracy of the Formulary, UM files, and Pharmacy Benefits for the annual BID submission to CMS.
• Prepares Formulary/Pharmacy Benefits Industry Analysis annually.
• Complies and implements Inflation Reduction Act requirements with PBM and CMS Innovation Programs, as needed.
• Monitors drug pipeline, drug trends, and payer industry changes throughout the year to identify potentially high Part D impact drugs.
• Manages Part B drug trend and value-based opportunities.
• Oversees PBM operations in the areas of Formulary, Opioid Safety Edits, Pharmacy Benefits, Transition Programs, Prescriber Enrollment Requirements and Pharmacy Network Implementation.
• Ensures AEP and 1/1 readiness and assists in training of other departments.
• Serves as the clinical subject matter expert for respective areas, providing guidance as needed.
• Maintains current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance and implementing changes to maintain compliance.
• Manages multiple deadlines and completes projects with 100% accuracy.
• Maintains professional and technical knowledge by conducting research and by attending educational and technological workshops.
• This position requires contributions to team efforts by accomplishing and sharing related results with other staff.
• Collaborates with other team members within the Pharmacy Department; collaborates with other SCAN departments: Compliance, Marketing, HCI, Product, Member Services to support the achievement of SCAN’s Vision and Goals.
• Actively support the achievement of SCAN’s Vision and Goals.
• Other duties as assigned.

Benefits

• Base salary range: $125,400 to $181,419 per year.
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• 11 paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree