Job DescriptionYour Role The Formulary Strategy and Management team develops and maintains formularies that support competitive health plan products, manage health care costs, and meet regulatory requirements across Commercial Large Group, Commercial Small Group, Individual/Family, and Medicare lines of business. The Senior Manager, Pharmacist of Formulary Management reports to the Director, Formulary Strategy and Pharmacy & Therapeutics.
In this role, you will lead a team of pharmacists and operations specialists responsible for formulary operations, Centers for Medicare & Medicaid Services (CMS)/Medicare formulary and utilization management (UM) submissions, System for Electronic Rates and Forms Filing (SERFF) submissions, formulary and UM implementation and adjudication accuracy. You will partner with analytics, product, actuary, operations, vendors, and other business partners to develop and execute strategies that improve affordability, quality, compliance, and member experience.
ResponsibilitiesYour Work In this role, you will:
- Lead day-to-day formulary operations and team performance to support compliant, accurate, and timely execution
- Develop formulary strategies using clinical evidence, treatment guidelines, claims analysis, competitive intelligence, drug pipeline information, and financial and market data
- Oversee accurate installation of drug formularies and UM rules to support compliant claims adjudication
- Ensure compliant CMS/Medicare formulary and UM submissions, SERFF submissions, formulary collateral, and change notices that support member and provider transparency
- Partner with cross-functional teams and vendors to coordinate implementation, monitor performance, and meet accreditation, regulatory, and compliance requirements
- Identify opportunities to improve quality, affordability, operational efficiency, and performance against benchmarks
- Support pharmacy resident and student precepting, as assigned
QualificationsYour Knowledge and Experience - Doctor of Pharmacy (PharmD) degree from an accredited school of pharmacy in the US.
- Active and unrestricted California Registered Pharmacist (RPh) license
- At least 8 years of managed care pharmacy experience
- 4 years of people management experience with direct responsibility for supervising, coaching, and evaluating direct reports
- Experience with Medicare, ACA, Exchange, CMS/Medicare formulary and UM submissions, SERFF submissions, and other applicable regulatory requirements
- Demonstrated ability to lead formulary and UM processes, projects, timelines, and cross-functional implementation activities
- Strong independent judgment, analytical thinking, problem-solving skills, and ability to use data to drive decisions and results
- Thorough knowledge of managed care and pharmacy benefit management practices, including UM
- Advanced proficiency with Microsoft Office applications, including Excel, Access, and PowerPoint
HybridThis role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
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.
Please click here for further physical requirement detail.
