Formulary Operations Manager - Exchange

Position Summary:

The Formulary Operations Manager is responsible for providing operational support for the evaluation, implementation, and maintenance of our standard and custom Commercial and Exchange formularies and utilization management. This individual supports the creation and maintenance of formulary, clinical adjudication list, and utilization management lists, preparation of Exchange JSON formulary submission 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 formulary operations processes.

Position Responsibilities:

• Define, configure, and maintain standard and custom formularies for the Commercial and Health Information Marketplace/Exchange lines of business

• Provide client-facing strategic and operational support for the configuration, implementation, maintenance, and quality control of custom formularies, drug lists, custom formulary marketing materials, clinical adjudication lists, and utilization management edits

• Evaluate appropriateness and operationalize custom client formulary and benefit requests within the formulary / adjudication platform

• Collaborates with teams in a cross-functional environment including, but not limited to; benefit administration, rebate administration, client account management, analytics, software development/product, regulatory/compliance, government programs, member experience, prior authorization operations, and marketing

• Develop weekly drug product review and formulary recommendations by assessing drug use trends, new drug releases, and review of primary literature

• 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 reporting requirements

• Evaluate drugs/drug classes and make formulary positioning and utilization management recommendations and formulary management strategies and associated adjudication requirements to operationalize

• Provide cross functional support for claim troubleshooting within the adjudication platform

• Support comprehensive testing of client formulary and benefit elections

• Support formulary change processes within URAC/NCQA/SOC guidelines and requirements

• Support client formulary requests, as required

• Support quality improvement projects, as required

• Support the Capital Rx pharmaceutical pipeline, as needed

• Support Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed

• Support general business needs and operations, as required
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Minimum 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

• 2-3 years of formulary experience working for a health plan or PBM preferred

• 2-3 years of Medicare experience preferred

• Knowledge of formulary development and maintenance processes

• Knowledge of highly managed specialty medications/strategy

• Knowledge of rebate and financial implications of formulary strategies

• 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 & commitment to delivering high quality work product

• Microsoft office suite with emphasis on Microsoft excel proficiency required

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.