Summary of JobResponsible for setting Pharmacy UM criteria and decision tree oversight. Review and maintain UM criteria (e.g., prior authorization (PA) and step therapy) for clinical appropriateness and alignment with P&T decisions. Advise Operations team on vendor configuration for UM setup. Partner with pharmacist Formulary, UM, and analytics teams to select annual formulary. Partner with Finance and Pharmacy analytics to finalize disruption analysis and monitor medical drug rebates. Provide formulary analysis for strategy opportunities, collaborate with Ops/Product strategy team to inform benefit design. Advise pharmacy benefits manager (PBM) and operations team to implement formulary and prior authorization criteria. Monitor key PGs, KPIs, and trends in utilization, authorization, and operations; report metrics to Formulary and UM Pharmacist Manager and Clinical Pharmacy Director. Provide sound clinical judgment and subject matter expertise of State and Federal regulations to ensure compliance with regulatory and contractual obligations.
Responsibilities- Responsible for development, implementation, and maintenance of preferred formulary drug lists.
- Responsible for preferred drug lists for key clinical areas including primary care, pediatrics, dermatology, cardiology, ophthalmology, rheumatology, hematology/oncology, gastroenterology.
- Develop preferred formulary drug lists across all lines of business: Medicare Part D, Medicaid, Commercial, Healthcare Exchange.
- Evaluate and maintain formulary set-up based on clinical requirements, compliance with regulatory bodies, and P&T rules.
- Maintain clinical tools utilized by pharmacy services for purpose of remaining up to date and compliant with current pharmacy policies.
- Provide education on new formulary updates including quarterly formulary changes and annual 1/1 changes.
- Serve as subject matter expert for all escalated clinical formulary related issues as well as for all formulary related internal and external audits.
- Review weekly reports to identify trends and compliance.
- Work with IT to maintain preferred drug list updates.
- Identify and target prescribing outliers.
- Work with actuary to determine cost saving alternatives for preferred drug list.
- Manage the Pharmacy & Therapeutic Committee/Formulary Management, including Step-Protocol Review, Non Formulary Review, Subcommittee Management (Meetings/minutes), Drug Reviews, and Updates and Drug Policies, for all medications.
- Report formulary compliance to senior leadership.
- Other duties/projects as assigned
Qualifications- Doctor of Pharmacy degree
- PGY-1 or PGY-2 In Ambulatory Care, Geriatrics, Internal Medicine, or Managed Care (Preferred)
- Registered Pharmacist: Registered Pharmacist license (Requred)
- 10 - 12+ years of relevant experience (Requred)
- Residency or 5 years' clinical experience (Preferred)
- Knowledge of formulary utilization management techniques (Requred)
- Knowledge of pharmaceuticals and disease states to provide advice and consultation to providers and members and recommend changes to the formulary (Requred)
- Possess research and analytical skills sufficient to provide problem resolution and consultation to providers (Requred)
- Excellent verbal and written communication skills sufficient to prepare own correspondence and interact with members and providers in provision of advice and guidelines (Requred)
