Capital Rx
Formulary Operations Pharmacist - Medicare
Capital Rx, New York, New York, us, 10261
Formulary Operations Pharmacist - Medicare
Position Summary:The Formulary Operations Pharmacist - Medicare is responsible for providing operational support for the evaluation, implementation, and maintenance of Medicare Part D formularies and utilization management. This individual supports 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:Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelinesSupport development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug listsLead and support preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, andutilization management criteriaEvaluate drugs/drug classes, make formulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalizeEvaluate appropriateness of and operationalize custom client formulary and benefit change requests within the formulary and adjudication platformSupport comprehensive testing of client formulary and benefit electionsProvide cross functional support for claim troubleshooting within the adjudication platformMonitor and analyze regulatory and legislative requirements for MedicareSupport development of project plans to meet new CMS requirements, and support cross functional teams with implementation of programs to meet requirementsLead formulary change processes within URAC/NCQA/CMS guidelinesPharmacy and Therapeutics (P&T) Committee participation as an ad hoc memberConduct formulary reviews and develop drug monographs based on a rotation of clinical pharmacistsMaintain and update the Capital Rx pharmaceutical pipeline, as neededDevelop clinical criteria for review as neededSupport CMS formulary administration auditsSupport quality improvement projects as neededSupport Request for Information (RFI) and Request for Proposal (RFP) submissions, as neededSupport general business needs and operations, as neededResponsible 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 performanceCurrent, unrestricted registered pharmacist license(s)Residency/fellowship preferred2-3 years of formulary experience working for a health plan or PBM preferred2-3 years of Medicare experience preferredKnowledge of formulary development and maintenance processesKnowledge of highly managed specialty medications/strategyKnowledge of rebate and financial implications of formulary strategiesExperience working with large datasets preferredAbility to independently identify, research, and resolve issuesAbility to balance multiple complex projects simultaneouslyAbility to work extended hours, weekends, and holidays consistent with industry demandsExceptional written and verbal communication skillsExtremely flexible, highly organized, and able to shift priorities easilyAttention to detail & commitment to delivering high quality work productMicrosoft office suite with emphasis on Microsoft excel proficiency required
Base Salary: $125,000 - $130,000Nothing in this position description restricts management's right to assign or reassign duties and responsibilities to this job at any time.About Capital RxCapital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation's electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp, Capital Rx is executing its mission through the deployment of JUDI, the company's cloud-native enterprise health platform, and a Single-Ledger Model, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.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 lawsApply For This Position
Position Summary:The Formulary Operations Pharmacist - Medicare is responsible for providing operational support for the evaluation, implementation, and maintenance of Medicare Part D formularies and utilization management. This individual supports 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:Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelinesSupport development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug listsLead and support preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, andutilization management criteriaEvaluate drugs/drug classes, make formulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalizeEvaluate appropriateness of and operationalize custom client formulary and benefit change requests within the formulary and adjudication platformSupport comprehensive testing of client formulary and benefit electionsProvide cross functional support for claim troubleshooting within the adjudication platformMonitor and analyze regulatory and legislative requirements for MedicareSupport development of project plans to meet new CMS requirements, and support cross functional teams with implementation of programs to meet requirementsLead formulary change processes within URAC/NCQA/CMS guidelinesPharmacy and Therapeutics (P&T) Committee participation as an ad hoc memberConduct formulary reviews and develop drug monographs based on a rotation of clinical pharmacistsMaintain and update the Capital Rx pharmaceutical pipeline, as neededDevelop clinical criteria for review as neededSupport CMS formulary administration auditsSupport quality improvement projects as neededSupport Request for Information (RFI) and Request for Proposal (RFP) submissions, as neededSupport general business needs and operations, as neededResponsible 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 performanceCurrent, unrestricted registered pharmacist license(s)Residency/fellowship preferred2-3 years of formulary experience working for a health plan or PBM preferred2-3 years of Medicare experience preferredKnowledge of formulary development and maintenance processesKnowledge of highly managed specialty medications/strategyKnowledge of rebate and financial implications of formulary strategiesExperience working with large datasets preferredAbility to independently identify, research, and resolve issuesAbility to balance multiple complex projects simultaneouslyAbility to work extended hours, weekends, and holidays consistent with industry demandsExceptional written and verbal communication skillsExtremely flexible, highly organized, and able to shift priorities easilyAttention to detail & commitment to delivering high quality work productMicrosoft office suite with emphasis on Microsoft excel proficiency required
Base Salary: $125,000 - $130,000Nothing in this position description restricts management's right to assign or reassign duties and responsibilities to this job at any time.About Capital RxCapital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation's electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp, Capital Rx is executing its mission through the deployment of JUDI, the company's cloud-native enterprise health platform, and a Single-Ledger Model, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.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 lawsApply For This Position