Formulary Operations Pharmacist

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including Judi Rx (a public-benefit PBM for self-insured employers), Judi Health™ (full-service health benefit management), and Judi®, the industry’s leading Enterprise Health Platform that consolidates all claim-administration workflows in one scalable, secure platform. Together with our clients, we’re rebuilding trust in U.S. healthcare.

About the role

The Formulary Operations Pharmacist – Medicare provides operational support for the evaluation, implementation, and maintenance of Medicare Part D formularies and utilization management. This role supports the creation and upkeep of formulary and utilization-management lists, prepares CMS formulary files and member drug lists, reviews updates for implementation, and handles other formulary-related tasks. Strong cross-functional collaboration, communication skills, and a deep understanding of Medicare Part D formulary processes and CMS regulations are essential. The position also supports non-Medicare formulary tasks as needed.

Location: Hybrid (local to New York, New York; Denver, Colorado; or Charlotte, North Carolina area).

Responsibilities

• Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelines.
• Support the development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug lists.
• Lead and support the preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists, look-up tools, and utilization management criteria.
• Expand scope of responsibilities across other non-Medicare business lines when needed, driving alignment, operational excellence, and strategic execution.
• Evaluate drugs and drug classes to provide formulary positioning and utilization management recommendations; update formulary management strategies and operationalize adjudication requirements.
• Evaluate and operationalize custom client formulary and benefit change requests within the formulary and adjudication platform.
• Create customized marketing materials, including member formulary drug lists, utilization management criteria documentation, and web-based look-up tools.
• Support comprehensive testing of client formulary and benefit elections.
• Support custom formulary client trade and rebate strategy evaluation.
• Identify opportunities for automation and collaborate with Analytics to streamline processes and workflows.
• Analyze pharmacy cost of care and clinical updates for the development of formulary management programs and utilization management edits.
• Provide clinical support to operational teams and clients during implementations.
• Serve as the clinical operations liaison for ad-hoc sales requests and strategic client communications, offering expert clinical insights.
• Perform quality assurance checks of Formulary Specialist activities, emphasizing adjudication accuracy.
• Provide cross-functional support for claims troubleshooting within the adjudication platform.
• Monitor and analyze regulatory and legislative requirements for Medicare.
• Lead and support timely submission of all required reporting to State and Federal regulators, such as formulary submissions to Health Plan Management System (HPMS).
• Support the development of project plans to meet new CMS requirements and assist cross-functional teams with implementation.
• Lead formulary change processes within URAC/NCQA/CMS guidelines.
• Support Pharmacy and Therapeutics (P&T) committee items as required.
• Maintain and update the Rx pharmaceutical pipeline, develop monthly newsletters, and other client communications.
• Develop clinical criteria for review as needed.
• Support CMS Program Audits as a formulary administration subject matter expert; provide input for auditor-requested deliverables, including root cause analysis, beneficiary impact analysis, and corrective action plans.
• Support Quality Improvement projects, clinical value projects, and continuous improvement initiatives.
• Support Request for Information (RFI) and Request for Proposal (RFP) submissions.
• Support general business needs and operations.
• Review new regulatory guidance impacting formulary administration and provide compliant-action guidance to stakeholders.
• Maintain compliance with all regulatory and organizational deadlines.
• Adhere to the Judi Rx Code of Conduct, including reporting noncompliance.
• Perform other duties and responsibilities as needed.

Requirements

• Doctor of Pharmacy (PharmD) Degree from an accredited institution.
• Current, unrestricted registered pharmacist license(s).
• Residency/fellowship preferred.
• 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.
• 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 and commitment to delivering high-quality work.
• Proficient in Microsoft Office Suite, with strong emphasis in Microsoft Excel.

Pay

Salary ranges:

• Remote (U.S.): $125,000 – $135,000 USD
• New York, NY: $125,000 – $135,000 USD
• Denver, CO: $125,000 – $135,000 USD
• Charlotte, NC: $125,000 – $135,000 USD