Note: The job is a remote job and is open to candidates in USA. Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. 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, requiring strong cross functional collaboration and communication skills.
Responsibilities
- Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelines
- Supports the development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug lists
- Leads and supports the preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, and utilization management criteria
- Expanded scope of responsibilities across other non-Medicare business lines when needed, driving alignment, operational excellence, and strategic execution across diverse functions
- Evaluate drugs and drug classes, to provide formulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalize
- Evaluates the appropriateness of and operationalizes custom client formulary and benefit change requests within the formulary and adjudication platform
- Creates customized marketing materials, including but not limited to member formulary drug lists, utilization management criteria documentation, and web-based look up tools
- Supports the comprehensive testing of client formulary and benefit elections
- Supports custom formulary client trade and rebate strategy evaluation
- Identifies opportunities for automation and collaborates with Analytics to streamline processes and workflows
- Analyzes pharmacy cost of care and clinical updates for the development of formulary management programs and utilization management edits
- Provides clinical support to operational teams and clients during implementations
- Serves as the clinical operations liaison to assist with ad-hoc sales requests and strategic communications for clients to provide expert insights from a clinical perspective
- Quality assurance checks of Formulary Specialist activities, with emphasis on actions impacting adjudication of claims for accuracy
- Provides cross functional support for claims troubleshooting within the adjudication platform
- Monitors and analyzes regulatory and legislative requirements for Medicare
- Leads and supports timely submission of all required reporting to State and Federal regulators, such as required formulary submissions to Health Plan Management System (HPMS)
- Supports the development of project plans to meet new CMS requirements, and supports cross functional teams with implementation of programs to meet requirements
- Leads formulary change processes within URAC/NCQA/CMS guidelines
- Supports Pharmacy and Therapeutics (P&T) committee items, as required
- Maintains and updates the Rx pharmaceutical pipeline, development of monthly newsletters, and other client communications as needed
- Develops clinical criteria for review as needed
- Supports CMS Program Audits as a formulary administration subject matter expert and provide necessary input of information to complete any auditor requested deliverables, including but not limited to root cause analysis, beneficiary impact analysis, and corrective action plans
- Supports Quality Improvement projects, clinical value projects, and continuous improvement initiatives, as needed
- Supports Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed
- Support general business needs and operations, as needed
- Supports review of new regulatory guidance and regulations that impact formulary administration and provide guidance to internal and external stakeholders for compliant action
- Maintains compliance with all regulatory and organizational deadlines
- Responsible for adherence to the Judi Rx Code of Conduct including reporting of noncompliance
- Performs other duties and responsibilities as needed
Skills
- Doctor of Pharmacy (PharmD) Degree from an accredited institution
- Current, unrestricted registered pharmacist license(s)
- 2+ years of Medicare formulary experience working for a health plan or PBM
- 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 required
- 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
- Proficient in Microsoft office suite with strong emphasis in Microsoft Excel required
- Residency/fellowship preferred
Benefits
- Location: Hybrid (Local to New York, New York; Denver, Colorado; or Charlotte, North Carolina area)
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