Job Description

Your 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. 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 efforts with formulary for pharmacy claim adjudicator and other vendors to ensure maintenance, validation, and audits are compliant with business needs. You will support in the development and maintenance of the formularies for all Blue Shield lines of business - Commercial, Exchange, and Medicare.

This role is responsible for supporting day-to-day operations, maintaining of formulary and drug list databases, supporting P&T materials and documentation, maintaining desk-level procedures as well as job aids, and creating reports. The Operations Specialist, Senior will collaborate with the pharmacy claim adjudicator, analytics, benefits and claims, Pharmacy Market Experience, Compliance, prior authorization, and customer services departments to communicate formulary and utilization management changes, formulary intent, and to ensure that formulary decisions are implemented in accordance with business rules and regulatory requirements.

Responsibilities

Your Work

In this role, you will:

• 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 effectuation of BSC formularies; notify appropriate managers of formulary issue requiring immediate attention for resolution; determine appropriate workflow required for maintaining formulary decisions
• Develop and evaluate 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. Assist with updating content and web posting requirements including drug coverage requirements such as prior authorization and step therapy criteria.
• Participate as a subject matter expert in the development of written guidelines and documents desk level procedures and policy and procedures
• Maintain and adheres 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
• Coordinates 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)
• Act as subject matter expert of formulary operational workflows for implementing formulary decisions in compliance with state and federal regulations and audits
• Occasional business travel required
• Other duties as assigned.

Qualifications

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires at least 5 years of prior relevant experience within Pharmacy Services (e.g., claims, customer service, benefits, prior authorization, formulary)
• Experience working with Pharmacy Benefit Management systems or vendors
• Knowledge of Pharmacy Benefit design and Formulary configuration; knowledge of Blue Shield of California (or similar health care organization) pharmacy configuration is preferred
• Requires California Pharmacy Technician Certification
• Requires strong skills in standard Microsoft Office applications (e.g., Excel, Word, Outlook)
• Strong coordination and interpersonal skills working in a matrixed environment with multiple stakeholders
• Familiarity with Medispan drug files is preferred
• Experience in practical project management is preferred
• Demonstrated experienced identifying and resolving complex problems related to automated systems and operations within functional area
• 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 requirements is preferred

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

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