Clinical Pharmacist, Formulary Management Regulatory

CVS Health-posted 2 months ago
$118,000 - $206,250/Yr
Full-time • Mid Level
Buffalo Grove, IL
5,001-10,000 employees
Ambulatory Health Care Services
Resume
Match Score
Upload and Match ResumeTrack Jobs with Teal

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

  • Ensure template formularies design and application of utilization management (UM) criteria align with MHPAEA and other federal/state regulations.
  • Support PBM market conduct examinations, CMS audits, and internal regulatory reviews.
  • Partner with Government Affairs, Legal, and Compliance teams to produce and validate data for exam requests.
  • Develop and maintain CVS Caremark's template formularies including drug tiering and UM application that meet or exceed regulatory requirements.
  • Evaluate consistency in UM application across medical/surgical and mental health/substance use disorder drugs.
  • Identify the Evidentiary Standards, Factors and Sources supporting the development and application of Non-Quantitative Treatment Limitations (NQTLs).
  • Provide QA and sign-off on audit responses and corrective action plans.
  • Understand UM development and management, including prior authorization, step therapy, quantity limits, and formulary exceptions.
  • Recognize decisions reflect clinical best practices and regulatory requirements.
  • Serve as a liaison between Formulary Management and internal/external stakeholders including CVS Audit Team, Legal, Compliance and Regulatory Affairs.
  • Collaborate in a matrixed environment with colleagues across departments and levels.
  • Present findings and recommendations to leadership and regulatory partners.
  • PharmD or equivalent clinical pharmacy degree.
  • Active pharmacist license in good standing.
  • Ability and willingness to work in a hybrid structure role requiring employees work 3 days/week in office at either our Buffalo Grove, IL or Pittsburgh, PA office locations.
  • 3-5 years of experience in regulatory pharmacy, utilization management, or PBM operations.
  • 3+ years of managed care experience.
  • 3+ years of relevant UM or prior authorization experience.
  • Strong understanding of MHPAEA, CMS regulations, and market conduct exam processes.
  • Demonstrated understanding of UM interventions (prior authorization, step therapy, quantity limits, formulary exceptions).
  • Proven proficiency in literature search and evidence-based medicine analysis.
  • Experience with internal audits, external regulatory reviews, and market conduct examinations.
  • Excellent written and oral communication skills, with the ability to distill complex concepts for leadership.
  • Project and process management experience.
  • Ability to understand and optimize complex workflow processes.
  • Skilled in MS Office applications (Word, Excel, Access, PowerPoint).
  • Experience supporting audits and regulatory reviews in a PBM or managed care setting.
  • Familiarity with mental health and substance use disorder treatment guidelines.
  • Ability to manage complex projects and cross-functional initiatives.
  • Acumen specific to Specialty Pharmacy, Utilization Management, Formulary Management.
  • Knowledge of Regulatory Rules and Requirements.
  • Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
  • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
  • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
Track Jobs with Teal

Job Search Resources

•
Resume Builder
•
Resume Examples
•
Cover Letter Examples

Tools

Career Hubs

Guides

Company

© 2024 Teal Labs, Inc
Privacy PolicyTerms of Service