Formulary Maintenance Operations Manager Job in San Diego 92131, California US
The Formulary Maintenance Operations Manager will manage operational aspects of business unit, department, and strategic initiatives, projects, and/or programs. They will focus on efforts of the MedImpact Formulary Maintenance Team in quality control and analysis of MedImpact client formulary set-up, rule sets, coding, accuracy, functionality, EOB, documentation and concordance with client specified and regulatory requirements utilizing distinct but inter-related management and cross-departmental functions. This individual will promote rational and appropriate drug use in the Medicare population and will provide direct client clinical consultation relative to Part D formulary drug placement, appropriate utilization management edits and related client specific Word documents for Step Therapy and Prior Authorization Guidelines required by CMS. They will ensure appropriate, accurate and consistent client specific Part D formulary claims adjudication, formulary flat file and Plan Finder file concordance and will provide direct client consultation on all Formulary Services formulary maintenance operations, programs, and software. It is important that the Formulary Maintenance Operations Manager coordinate quality control and analytics related to the Part D MedImpact Standard and Custom formularies Formulary Change process including appropriate formulary content, application of utilization management activities, printed formularies, Plan Finder formulary files and other functions as required. In addition they will ensure that the review, coding and quality control of formulary changes occur in an appropriate, accurate, and timely manner based on client-specific parameters.
The successful candidate will ensure compliance with regulatory requirements for Part D formularies and will provide direct client consultation on CMS statutory regulations and CMS issued regulatory guidance to ensure continued CMS formulary approval. They will create, modify, maintain and oversee the MedImpact Medicare Part D Medication Therapy Management (MTM) Program for all MedImpact clients who elect to participate. Activities include creation of program criteria, policies and procedures and functional operation to ensure program success and program goal achievement of enhanced therapeutic outcomes for targeted plan beneficiaries through improved medication use. This individual will monitor changes and regulatory guidance relative to MTM and make all appropriate adjustments to guarantee compliance and will monitor drug vendor and regulatory bodies for operational or strategic market changes to ensure rapid and successful adjustments and application to MedImpact processes. As an integral team member, the Formulary Maintenance Operations Manager will maintain and oversee the Part D MedImpact Standard and Custom formulary print functions in accordance with CMS regulatory statute and guidance and will review new drug categorization changes to customize, implement, and integrate with MedImpact printed formulary products as appropriate. In addition, they will provide formulary-specific documentation of maintenance activities to clients and regulatory bodies and will establish and maintain a process to provide Explanation of Benefits formulary changes to Medicare Part D formulary clients.
Requirements:
For consideration candidates will need a minimum of a R.Ph. degree and Pharm.D, or equivalent combination of education and experience and five (5) to seven (7) years of related experience.
Prior experience in PBM/Benefits Services formulary setup and maintenance, relational and analytical database management programs, as well as familiarity with First DataBank and/or Medispan drug files is desirable. Prior experience with Medicare Part D and CMS formulary submission and maintenance processes is preferable. To perform this job successfully an individual must be able to execute and deliver within the confines and timeframes provided by CMS which may include non-standard business hours.