Operations Specialist, Senior

Blue Shield of California • Oakland, CA

5d • $92,380 - $138,508 • Hybrid

About The Position

The Formulary Management team leads the maintenance of multiple formularies to support competitive health plan products and meet regulatory requirements for all lines of business including Commercial Large Group, Commercial Small Group, Individual/Family plan, and Medicare. The Operations Specialist, Senior will report to the Senior Manager of Formulary Management. In this role you will be a subject matter expert who will lead formulary implementation with the pharmacy claim adjudicator and other vendors to ensure maintenance, validation, and audits are compliant with business needs. This role is responsible for supporting day-to-day operations, maintaining of formulary and drug list databases, maintaining desk-level procedures as well as job aids, and creating reports. The Operations Specialist, Senior will collaborate cross functionally with the pharmacy claim adjudicator, analytics, benefits and claims, communications, compliance, prior authorization, and customer services departments to communicate formulary and utilization management changes, formulary configuration, and to ensure that formulary decisions are implemented in accordance with health plan client business rules and regulatory requirements. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Requirements

• Subject matter expert in formulary management.
• Experience with pharmacy claim adjudicators and other vendors.
• Experience in maintaining formulary and drug list databases.
• Experience in maintaining desk-level procedures and job aids.
• Experience in creating reports.
• Cross-functional collaboration skills.
• Understanding of health plan client business rules and regulatory requirements.

Responsibilities

• Lead formulary implementation with the pharmacy claim adjudicator and other vendors to ensure maintenance, validation, and audits are compliant with business needs.
• Support day-to-day operations.
• Maintain formulary and drug list databases.
• Maintain desk-level procedures and job aids.
• Create reports.
• Collaborate cross functionally with the pharmacy claim adjudicator, analytics, benefits and claims, communications, compliance, prior authorization, and customer services departments to communicate formulary and utilization management changes, formulary configuration, and to ensure that formulary decisions are implemented in accordance with health plan client business rules and regulatory requirements.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed