Senior Formulary Operations Manager - Medicare

Capital Rx
US - New York - New York
January 22, 2025

This position is responsible for providing operational support for the evaluation, implementation, and maintenance of both custom and standard Medicare Part D formularies and utilization management.
Additionally, this role will be client facing when supporting new client implementations, will be the strategic Medicare focused formulary leader within the organization, and support onsite Medicare formulary administration audits.
This individual will lead the creation and maintenance of formulary and utilization management lists, preparation of CMS formulary files and member formulary drug lists, preparation and review of updates for implementation, and other formulary and utilization management related tasks and processes.
The role requires strong cross functional collaboration and communication skills, and an understanding of Medicare Part D formulary management processes and related CMS rules and regulations.

Position Responsibilities:

Define, develop, and maintain standard and custom formularies for Medicare Part D line of business per CMS Medicare Part D guidelines
Provide strategic and operational leadership and support for the development, implementation, maintenance, and quality control of Medicare Part D formularies, drug lists, and utilization management
Evaluate appropriateness and operationalize custom client formulary and benefit requests within the formulary/adjudication platform
Cross functional support for claim troubleshooting through the adjudication platform
Lead and support preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, and utilization management criteria
Support comprehensive testing of client formulary and benefit elections
Analyze pharmacy cost of care, clinical updates, and coordinate the development of appropriate formulary management programs and utilization management edits
Set criteria for medication analysis and coordinate methodology for client requested and regulatory formulary requirements
Support development of project plans to meet new CMS requirements, and support cross functional teams with implementation of programs to meet requirements
Lead formulary change processes within URAC/NCQA/CMS guidelines
Evaluate drugs/drug classes and make formulary positioning and utilization management recommendations
Support CMS formulary administration audits
Support quality improvement projects as needed
Support Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed
Support general business needs and operations, as needed
Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Required Qualifications:

Doctor of Pharmacy (PharmD) Degree from an accredited institution, with record of strong academic performance
Current, unrestricted registered pharmacist license(s)
Residency/fellowship preferred
5+ years of pharmacy experience working for a health plan or PBM
3+ years of Medicare experience
Formulary development and maintenance process experience at a PBM or health plan required
Client facing experience preferred
Knowledge of highly managed specialty medications/strategy
Knowledge of rebate and financial implications of formulary strategies
Experience with custom client benefit and formulary design preferred
Experience working with large datasets preferred
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 product
Proficient in Microsoft office suite with emphasis on Microsoft excel required

Nothing in this position description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

About Capital Rx

Capital Rx is a next generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers, unions, and government entities.
Determined to transform an outdated model, Capital Rx's mission is to change the way prescription benefits are priced and administered in the US, unlocking enduring social change.
Through our platform approach, Capital Rx delivers data-driven insights and actionable strategies that reduce costs, while improving patient outcomes.
Our commitment to innovation, technology and service is the reason why Capital Rx is among the fastest-growing PBMs in the country.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table.
We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Read the full job description and apply online on the recuiter's web-site

Senior Formulary Operations Manager - Medicare

Senior Formulary Operations Manager - Medicare

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