Your Role
The Formulary Strategy and Management team leads the development and maintenance of multiple formularies to support competitive health plan products, manage cost-of-healthcare, and meet regulatory requirements for all lines of business including Commercial Large Group, Commercial Small Group, Individual/Family plan, and Medicare. The Sr. Manager, Pharmacist (Senior Manager of Formulary Management) will report to the Director, Formulary Strategy and Pharmacy & Therapeutics. In this role, you will lead formulary management for the Medicare line of business. You will collaborate with Analytics, Product, Actuary, Benefits, Communications, Regulatory teams, and other business areas to identify and implement interventions to manage cost of healthcare through formulary and utilization management optimization. The Senior Manager is responsible for managing a team of pharmacists and pharmacy technicians responsible for the day-to-day Medicare formulary operations to ensure compliant CMS submissions as well as implementation and validation of all formularies on the claims adjudication system and the formulary management system. The Senior Manager is also responsible for managing the relationship with multiple formulary related vendors and as well as CMS related to formulary compliance and audits.
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.Your Work
In this role, you will:
Provide oversight for the management of program area operations and employees
Be responsible for promotion and execution of overall vision, goals, objectives of the business unit
Provide oversight for the coordination of activities of the program area with other business units and monitor operational statistics to ensure all respective accreditation, regulatory and compliance requirements are met
Identify performance improvement opportunities to achieve or exceed benchmarks and advise on issues requiring immediate escalation
Provide oversight for the development, implementation, coordination, and assessment of programs to improve quality and cost-effectiveness
Lead development of Medicare formulary strategy for various market products, using clinical studies and guideline information, claims analyses, competitive intelligence, drug pipeline, financial and market data
Manage Medicare formulary operations including accurate installation of drug formularies for compliant claims adjudication and collaborating with Drug Utilization Review and Prior Authorization teams for accurate implementation of drug coverage policies and criteria for compliant coverage determinations
Oversee compliant Medicare formulary and Utilization Management (UM) submissions to regulators including creation and maintenance of all formulary collateral and formulary change notices for member/provider transparency, according to regulatory requirements
Provide oversight of vendor contracts and activities related to business functions and operations
Precept Pharmacy Practice Residents and students, as assigned
Your Knowledge and Experience
Requires a Doctor of Pharmacy (PharmD) degree
Requires at least 8 years of experience in a managed care setting, including at least 3 years of management experience or equivalent
Requires a currently active and unrestricted California Registered Pharmacist (RPh) license
Experience with Medicare, ACA, and Exchange regulatory requirements
Requires practical knowledge in leading and managing the execution of formulary and utilization management related processes, projects and timelines. Ability to multi-task, prioritize, and deliver in a demanding and constantly changing corporate environment
Proven record for driving to results through data-driven decision-making. Strong independent judgement, critical and analytics thinking, and problem-solving skills
Thorough knowledge of managed care and pharmacy benefit management practices, including utilization management
Advanced level skill and experience with MS Office applications including Access and Excel and PowerPoint
Pay Range:
The pay range for this role is: $145,970.00 to $218,900.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
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