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Dir., Formulary & Drug Policy Dev.

Job Description

Summary of Job:
Responsible for development and maintenance activities for formularies on the following lines of business: Medicare Part D, Medicaid, Commercial,  Healthcare Exchange.  Responsible for formulary setup, maintenance, and compliance with CMS. Responsible for P&T Committee meeting readiness, preparation and follow up.  Ensure clinical staff is leveraged and engaged appropriately. Responsible to ensure new drug pipeline is updated weekly and maintained. Work with data analytics to identify members impacted by formulary changes and ensure member mailings and provider communications are sent timely. Interface with PBM regarding rebates for pharmacy drug claims, formulary administration and clinical rule execution.  Responsible for the development and implementation of Medical Pharmacy initiatives including: medical prior authorizations, medical claim edits, medical drug criteria development and maintenance, site of care initiatives, preferred product determination, and rebate negotiations.


Responsibilities:

  • Establish a strategic approach to product formulary management; partner with Express Scripts in assessing industry best practices and trends; make timely recommendations to each product team leader; ensure appropriate filing documents are completed timely.
  • Ensure compliance with CMS regulations for Medicare formulary management for each of our H and S contracts; and that submissions and published guidebooks (monthly/quarterly) are accurate and timely.  
  • Ensure P&T Committee is effective and that the formulary team is well prepared for each quarterly meeting with appropriate, timely follow ups.  
  • Evaluate and maintain formulary set-up based on clinical requirements, compliance with regulatory bodies, and P&T approvals.  This also entails formulary monograph development, presentation at P&T Committee Meetings, annual criteria review, and website formulary and criteria postings.  
  • Define the clinical criteria for all drugs to be set up in ESI systems for utilization management.  
  • Ensure all drug policies are accurate, updated and posted in provider portals and other online services as required. 
  • Responsible to ensure that formulary information on the website for members and providers is accurate.  
  • Establish centers of excellence for the formulary team creating subject matter expertise for each line of business requirements.
  • Serve as subject matter expert for all escalated clinical formulary related issues as well as for all formulary related internal and external audits. Use sound clinical judgment and knowledge of regulations in ensuring compliance with regulatory and contractual obligations.
  • Evaluate and maintain formulary set-up based on clinical requirements, compliance with regulatory bodies, and P&T approvals.  This also entails formulary monograph development, presentation at P&T Committee Meetings, annual criteria review, and website formulary and criteria postings.  
  • Define the clinical criteria for all drugs to be set up in ESI systems for utilization management.  
  • Ensure all drug policies are accurate, updated and posted in provider portals and other online services as required. 
  • Responsible to ensure that formulary information on the website for members and providers is accurate.  
  • Contribute to the enterprise Pharmacy cost savings initiatives strategy.  This includes defining the value of agreed upon formulary changes including drug inclusion/exclusions, tier management and utilization management. 
  • Responsible for the development and implementation of Healthcare Cost of Care and Medical Cost savings initiatives for the department.  This includes identification, determining the savings potential by line of business with Actuary and medical economics, tracking success, and reporting.  
  • Oversee development, implementation, and reporting by initiative, provider collaborative, and line of business to track savings estimates and trend effectiveness.  
  • Other duties/projects as assigned or required.
     

Job Requirements

Qualifications:

  • Bachelor’s degree; Master’s in Business Administration preferred.
  • Doctor of Pharmacy degree.
  • PGY-1 or PGY-2 In Ambulatory Care, Geriatrics, Internal Medicine, or Managed Care preferred.
  • Registered Pharmacist: NYS pharmacy license; or will obtain license within 6 months of hire date.
  • 10+ years of relevant experience in Managed Care. (R)
  • Residency or 5 years’ clinical experience preferred (P)
  • Knowledge of formulary & utilization management techniques (R)
  • Knowledge of rebate strategy and negotiation (R)
  • Knowledge of medical pharmacy operations, trends and management techniques (R)
  • Knowledge of pharmaceuticals and disease states to provide advice and consultation to providers and members, and recommend changes to the formulary (R)
  • Possess research and analytical skills sufficient to provide problem resolution and consultation to providers (R)
  • Excellent verbal and written communication skills sufficient to prepare own correspondence and interact with members and providers in provision of advice and guidelines (R)
  • Ability to work cross functionally both in and out of the organization to accomplish goals (R)
     

Job Snapshot

Location US-NY-New York
Employment Type Full-Time
Pay Type Year
Pay Rate N/A
Store Type Health Care
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Company Overview

EmblemHealth

EmblemHealth is a local, neighborhood health plan that has served the New York City area and surrounding communities for more than 75 years. That’s the kind of experience that makes us unique. We’re proud to be one of the nation’s largest not-for-profit health plans, serving 3.1 million people who live and work across the New York tri-state area. Learn More

Contact Information

US-NY-New York
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Snapshot
EmblemHealth
Company:
US-NY-New York
Location:
Full-Time
Employment Type:
Year
Pay Type:
N/A
Pay Rate:
Health Care
Store Type:

Job Description

Summary of Job:
Responsible for development and maintenance activities for formularies on the following lines of business: Medicare Part D, Medicaid, Commercial,  Healthcare Exchange.  Responsible for formulary setup, maintenance, and compliance with CMS. Responsible for P&T Committee meeting readiness, preparation and follow up.  Ensure clinical staff is leveraged and engaged appropriately. Responsible to ensure new drug pipeline is updated weekly and maintained. Work with data analytics to identify members impacted by formulary changes and ensure member mailings and provider communications are sent timely. Interface with PBM regarding rebates for pharmacy drug claims, formulary administration and clinical rule execution.  Responsible for the development and implementation of Medical Pharmacy initiatives including: medical prior authorizations, medical claim edits, medical drug criteria development and maintenance, site of care initiatives, preferred product determination, and rebate negotiations.


Responsibilities:

  • Establish a strategic approach to product formulary management; partner with Express Scripts in assessing industry best practices and trends; make timely recommendations to each product team leader; ensure appropriate filing documents are completed timely.
  • Ensure compliance with CMS regulations for Medicare formulary management for each of our H and S contracts; and that submissions and published guidebooks (monthly/quarterly) are accurate and timely.  
  • Ensure P&T Committee is effective and that the formulary team is well prepared for each quarterly meeting with appropriate, timely follow ups.  
  • Evaluate and maintain formulary set-up based on clinical requirements, compliance with regulatory bodies, and P&T approvals.  This also entails formulary monograph development, presentation at P&T Committee Meetings, annual criteria review, and website formulary and criteria postings.  
  • Define the clinical criteria for all drugs to be set up in ESI systems for utilization management.  
  • Ensure all drug policies are accurate, updated and posted in provider portals and other online services as required. 
  • Responsible to ensure that formulary information on the website for members and providers is accurate.  
  • Establish centers of excellence for the formulary team creating subject matter expertise for each line of business requirements.
  • Serve as subject matter expert for all escalated clinical formulary related issues as well as for all formulary related internal and external audits. Use sound clinical judgment and knowledge of regulations in ensuring compliance with regulatory and contractual obligations.
  • Evaluate and maintain formulary set-up based on clinical requirements, compliance with regulatory bodies, and P&T approvals.  This also entails formulary monograph development, presentation at P&T Committee Meetings, annual criteria review, and website formulary and criteria postings.  
  • Define the clinical criteria for all drugs to be set up in ESI systems for utilization management.  
  • Ensure all drug policies are accurate, updated and posted in provider portals and other online services as required. 
  • Responsible to ensure that formulary information on the website for members and providers is accurate.  
  • Contribute to the enterprise Pharmacy cost savings initiatives strategy.  This includes defining the value of agreed upon formulary changes including drug inclusion/exclusions, tier management and utilization management. 
  • Responsible for the development and implementation of Healthcare Cost of Care and Medical Cost savings initiatives for the department.  This includes identification, determining the savings potential by line of business with Actuary and medical economics, tracking success, and reporting.  
  • Oversee development, implementation, and reporting by initiative, provider collaborative, and line of business to track savings estimates and trend effectiveness.  
  • Other duties/projects as assigned or required.
     

Job Requirements

Qualifications:

  • Bachelor’s degree; Master’s in Business Administration preferred.
  • Doctor of Pharmacy degree.
  • PGY-1 or PGY-2 In Ambulatory Care, Geriatrics, Internal Medicine, or Managed Care preferred.
  • Registered Pharmacist: NYS pharmacy license; or will obtain license within 6 months of hire date.
  • 10+ years of relevant experience in Managed Care. (R)
  • Residency or 5 years’ clinical experience preferred (P)
  • Knowledge of formulary & utilization management techniques (R)
  • Knowledge of rebate strategy and negotiation (R)
  • Knowledge of medical pharmacy operations, trends and management techniques (R)
  • Knowledge of pharmaceuticals and disease states to provide advice and consultation to providers and members, and recommend changes to the formulary (R)
  • Possess research and analytical skills sufficient to provide problem resolution and consultation to providers (R)
  • Excellent verbal and written communication skills sufficient to prepare own correspondence and interact with members and providers in provision of advice and guidelines (R)
  • Ability to work cross functionally both in and out of the organization to accomplish goals (R)
     

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