Job Details
Position Summary
This position will function as a point of contact for Pharmacy Services with the Pharmacy Benefit Manager (PBM) and other vendors to coordinate aspects of the Trust custom formularies for the commercial and Employer Group Waiver Plans. Additional responsibilities include coordinating specialty drug reviews with the medical carriers, analyzing pharmacy and medical claims data, evaluating industry utilization management trends, and recommending opportunities to improve performance of the prescription drug benefit.
Essential Functions
- Support the preparation of the agenda and supporting documents for the following meetings under the direction of the formulary manager:
-Weekly formulary clinical call with the Pharmacy Benefit Manager (PBM),
- Emerging Therapies Meetings (medication and program review) with the medical carrier
-New to market prescription drug reviews with leadership
- Capture recommendations and prepare decision documents as appropriate from the various meetings
- Responsible for the maintenance and upkeep of the Formulary Management/Formulary Repository system (example: MMIT or otherwise specified)
- Update coverage matrices as new clinical line extension coverage is approved
- Manager the Employer Group Waiver Plan (EGWP) calendar and formulary checklist to ensure
monthly and annual submissions to the Centers for Medicare & Medicaid (CMS) are met
- Review the member Guidebook for monthly and annual coverage updates
- Perform ad hoc outlier analysis for pricing and coverage discrepancies
- Identify and escalate issues that point to fraud, waste, and abuse Provide clinical supporting documentation for pharmacy initiatives
- Monitor & report PBM contract service level agreement items
- Monitor prescription drug regulations and trends
- Resolve member and carrier inquiries Coordinate member communications with Trust and PBM communication teams
- Validate drug utilization is trending appropriately based on benefit updates
- Update department processes and procedures as appropriate
- Prepare presentations, executive summaries, and other documentation to outline pharmacy
benefit opportunities for executive team review
- Collaborate with PBM account team in regular meetings to review clinical items and proposed
new initiatives
- Support Gaps in Care initiatives as they relate to prescription drug programs and adherence
- Support Formulary Manager with External Pharmacy Audit work
This list details the Trust s assignment of essential functions to this position. Other duties or tasks may be assigned to this position. This job description is subject to change at any time.
Technical Competencies
The ideal candidate will possess a unique combination of healthcare administration, pharmacy
formulary administration and business acumen.
Personal Effectiveness Competencies
All employees of the Trust are expected to demonstrate relevant personal effectiveness competencies as specified in the Trust s competency definitions.
Minimum Required Experience
- Pharmacy Technician (preferred) with 3 - 5 years of managed care pharmacy benefit administration and Medicare Part D (Employer Group Waiver Plan) formulary management
- Implement formulary management programs (i.e., utilization management, medication
adherence)
- Strong analytical skills to anticipate situations, define problems and formulate solutions.
- Demonstrated attention to details.
- Ability to work both independently and with a team.
- Able to organize and plan effectively with others.
- High level of interpersonal style and communication skills to work effectively with business
partners to meet mutual goals.
- Ability to articulate health care information to non-health care audience.
- Proficient in Microsoft Office applications (Excel, Word, and PowerPoint)
- High level of interpersonal communication skills to work effectively with business partners to
meet mutual goals.
- Written Communications - Writes clearly and informatively, edits work for spelling and grammar, varies writing style to meet the needs of the intended audience.
- Oral Communications- Comfortable presenting to large groups and ability to deliver a clear and effective presentations
Education, Professional Certifications and Licensure
Bachelor s degree in healthcare or related field
Working Conditions and Physical Effort
- physical requirements of this position are typical of office work.
- travel required.