Senior Clinical Pharmacist - Medicare Formulary Strategy

Job Description

We're seeking a Senior Clinical Pharmacist, Medicare Formulary Strategy to join our team! You will support the design, development, and execution of formulary strategies (Part D and Part

B) for all Medicare formularies, including MAPD (HMO, PPO, DSNP), PDP and EGWP. This role requires close collaboration with cross-functional partners-including Medicare Pharmacy Operations, UM Operations, Compliance, STARS, Medical Management, Actuary, Product, Clinical, and Finance teams to ensure formularies are clinically appropriate, cost-effective, competitive in the marketplace, and compliant with CMS regulations.

• Participate in the annual Medicare formulary planning process from kick-off through CMS submission and final approval.
• Assist with development and execution of Medicare formulary strategies that balance clinical efficacy, cost-effectiveness, compliance, and competitive positioning.
• Conduct competitive analyses, assess rebate and lowest net-cost opportunities, evaluate customer cohort profitability analyses, and product-specific strategies aligned with evolving product and market needs.
• Support the development of custom formularies tailored to the needs of each Medicare product.
• Research market trends, evaluate competitive positioning, and assess the regulatory landscape to guide Medicare formulary strategies.

• Participate in the Pharmacy & Therapeutics (P&T) and Business Assessment Committee, ensuring evidence-based decision-making and CMS compliance.
• Partner with Actuarial, Finance, Clinical and Product teams to model financial scenarios, assess member impact, and evaluate competitive positioning.
• Conduct ongoing and ad hoc reviews focused on specialty tiers, utilization management, STARS performance, and high-cost/high-trend drugs.
• Ensure P&T compliance with CMS regulatory standards.
• Work with PBM and internal partners to ensure CMS approval of formularies.

• Monitor emerging drug trends, competitive market dynamics, and utilization patterns to proactively identify opportunities or risks.
• Partner with Actuary and Data & Analytics teams to conduct analyses of formulary performance, including customer cohort profitability, trend tracking, UM performance, and tier exception reviews.
• Participate in refining strategy based on market intelligence and performance insights.

• Bachelor’s degree or advanced degree
• 5+ years of experience in related field
• In lieu of degree, 7+ years of experience in related field
• Licensed pharmacist or eligible for licensure in North Carolina.

• BA/BS in Pharmacy and a minimum of 5 years of Medicare managed care pharmacy experience; or any combination of education and experience, which would provide an equivalent background.
• Advance degree preferred (Pharm
  
  D, MBA, MPH, or equivalent).
• Minimum of 5 years of experience in Medicare Part D & B formulary management with a Medicare plan sponsor or pharmacy benefit manager (PBM).
• Strong understanding of Medicare Part D & B formulary requirements and regulatory guidance.
• Strong understanding of Medicare regulatory requirements for Pharmacy and Therapeutics Committees.
• Strong analytical, data interpretation, and trend management skills.
• Knowledge of Part D Stars measures and their application in formulary strategy.
• Excellent communication and presentation skills, with the ability to engage leadership and cross-functional stakeholders.
• Strategic planning and execution within the Medicare environment.
• Ability to synthesize clinical, financial, and regulatory insights into actionable strategies.
• Strong analytical and problem-solving abilities.
• Proven project management skills, including timeline development, prioritization, and cross-functional coordination.

This is a remote-optional position, but ideally would be located in the Raleigh-Durham area.

• The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community

• Work-life balance, flexibility, and the autonomy to do great work

• Medical, dental, and vision coverage along with numerous…