Operations Specialist, Experienced

About the role

The Formulary 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.

Responsibilities

• Maintain formulary databases and associated utilization management edits related to weekly drug updates and required for business operations related to Formulary Management for Commercial, Exchange, and Medicare lines of business.
• Review systems and applications and recommend system edits/changes as needed.
• Act as subject matter expert and review operational workflows, identifying problems and develop improvements, modifications, and enhancements; identify technical formulary issues that would prevent or delay CMS approval of BSC formularies; notify appropriate managers of Medicare formulary issue requiring immediate attention for resolution; determine appropriate workflow required for maintaining formulary decisions.
• Develop and evaluates tools and materials that enhance operating efficiency and accuracy related to Formulary management, both internal to the team and across the department and in conjunction with external vendors used to manage and maintain the formulary for all lines of business.
• Develop and transmit the documentation required to notify CMS of formulary, prior authorization criteria, and step therapy criteria changes.
• Develop required Commercial and Medicare printed formulary documents and work with the Pharmacy Communications, Medicare Marketing, and Web/Mobile teams to make these documents available in print and online.
• Aid in updating content and web posting requirements including drug coverage requirements such as prior authorization and step therapy criteria.
• Maintain and adhere to regulatory requirements for Department of Managed Health Care (DMHC), Exchange, and Medicare as subject matter expert related to formulary submissions, notification to internal/external stakeholders of changes to utilization management edits, and generation/distribution of collateral, including letters, websites, and formulary PDFs.
• Validate claims to ensure formulary implementation is consistent with formulary decisions and regulatory requirements.
• Coordinate operational implementation of formulary decisions as subject matter expert with internal teams (e.g., Drug Utilization Review, Pharmacy Benefit & Claims, Pharmacy Market Experience) and external teams (Pharmacy Benefits Adjudicator).
• Participate as a subject matter expert in the development of written guidelines and documents desk level procedures and policy and procedures.
• Act as subject matter expert of formulary operational workflows for implementing formulary decisions in compliance with state and federal regulations and audits.
• Occasionally travel for business.

Qualifications

• Requires a bachelor’s degree or at least 3 years of equivalent experience.
• Requires at least 2 years of prior relevant experience within Pharmacy Services (e.g., claims, customer service, benefits, prior authorization, formulary).
• Requires strong skills in standard Microsoft Office applications (e.g., Excel, Word, Outlook).
• Requires strong coordination and interpersonal skills working in a matrixed environment with multiple stakeholders.
• Familiarity with Medispan drug files is preferred.
• Broad knowledge of technical and operational practices of formulary decision documentation, regulatory submission, and implementation in the claims processing system is preferred.
• Knowledge of Medicare Part D and Commercial formularies is preferred.