Formulary Operations Pharmacist

About Judi Health

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Judi Rx
  , a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers,
• Judi Health
  , which offers full-service health benefit management solutions to employers, TPAs, and health plans, and
• Judi
  , the industry's leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform.

Together with our clients, we're rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit (Use the "Apply for this Job" box below)..

Location:

Hybrid (Local to New York, New York; Denver, Colorado; or Charlotte, North Carolina area)

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. The position also provide s support to non-Medicare formulary management tasks as opportunities arise.

• Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelines
• Supports the development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug lists
• Leadsand supports the preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, and utilization management criteria
• Expanded scope of responsibilities across other non-Medicare business lines when needed, driving alignment, operational excellence, and strategic execution across diverse functions
• Evaluate drugsanddrugclasses,toprovideformulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalize
• Evaluates the appropriateness of and operationalizes custom client formulary and benefit change requests within the formulary and adjudication platform
• Creates customized marketing materials, including but not limited to member formulary drug lists, utilization management criteria documentation, and web-based look up tools
• Supports the comprehensive testing of client formulary and benefit elections
• Supports custom formulary client trade and rebate strategy evaluation
• Identifies opportunities for automation and collaborates with Analytics to streamline processes and workflows
• Analyzes pharmacy cost of care and clinical updates for the development of formulary management programs and utilization management edits
• Provides clinical support to operational teams and clients during implementations
• Servesas the clinical operations liaison to assist with ad-hoc sales requests and strategic communications for clients to provide expert insights from a clinical perspective
• Quality assurance checks of Formulary Specialist activities, with emphasis on actions impacting adjudication of claims for accuracy
• Provides cross functional support for claims troubleshooting within the adjudication platform
• Monitor sand analyzes regulatory and legislative requirements for Medicare
• Leads and supports timely submission of all required reporting to State and Federal regulators, such as required formulary submissions to Health Plan Management System (HPMS)
• Supports the development of project plans to meet new CMS requirements, and supports cross functional teams with implementation of programs to meet requirements
• Leadsformulary change processes within URAC/NCQA/CMS guidelines
• Supports Pharmacy and Therapeutics (P&T) committee items, as required
• Maintain sand updatesthe Rx pharmaceutical pipeline,development of monthly newsletters, and other client communications as needed
• Develops clinical criteria for review as needed
• SupportsCMSProgram Audits as a formulary administration subject matter…