Company : Highmark Inc. Job Description : 

JOB SUMMARY

This position is a key member of a collaborative team responsible for the development, implementation, and maintenance of our organization's Medicare Part D formularies and Medicare Pharmacy Programs. Responsibilities include formulary design, pharmacy network management, development of prior authorization, quantity limits, and other utilization management strategies. All aspects of this work must adhere to federal and CMS requirements. The role requires a deep understanding of Medicare Part D regulations, including the implications of the Inflation Reduction Act, experience with CMS submission processes, and understanding of formulary administration and oversight. This individual will participate in cross-functional committees to ensure alignment with broader organizational strategies and contribute to initiatives aimed at improving Medicare Stars performance and Rx CAHPs outcomes. Leadership experience (formal or informal) is preferred, as this role involves guiding smaller teams to achieve common goals. Ideal candidates will possess strong analytical and problem-solving skills and have prior experience in formulary administration, pharmacy program or product development within a health plan or PBM setting; experience managing Medicare Part D plans is highly desired.

ESSENTIAL RESPONSIBILITIES

Monitor FDA-approvals, drug manufacturer pipelines,   assess drug utilization reports, and write drug monographs for Committee review to develop the Organization's Drug formulary and/OR provide recommendations for NDC code capture, and monthly identification of high risk members.  Gateway - Assist in the development of Gateway’s Drug Formularies by monitoring FDA-approvals and drug manufacturer pipelines, assessing drug utilization reports, and writing drug monographs for Pharmacy & Therapeutics Committee review. Assist in the development and implementation of utilization management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling  medical policy review and development, member facing outreach initiatives Develop and implement physician, pharmacy, account, and member educational initiatives that promote the Organization's Formularies, utilization management programs, and disease management initiatives. Provide clinical review and decisions including but not limited to:  physician and member appeals, member or provider information/education.  Participate on cross-functional committees to develop and implement clinical and operational initiatives within Integrated Clinical Services.  May participate in outreach efforts as needed to effectively reach goals of Medication Therapy Management programs to include, but not limited to Comprehensive Medication Reviews and Targeted Medication Reviews. Identify and assist in managing department process improvements to maximize overall efficiencies. Manage individual projects for timely review with the Director, Clinical Pharmacy. Participate in Medicare Stars performance measures to drive   contribution to excellence (5 Stars). Other duties as assigned or requested.

QUALIFICATIONS

Required

Bachelor of Science in Pharmacy with experience in clinical / formulary management or a Doctor of Pharmacy degree with experience in clinical formulary management 5 years of related, progressive experience int he area of specialization An understanding of managed care principles and practices is essential Demonstration of strong verbal and written communication skills, as well as, proficiency in the use of computer-based data processing Microsoft Office products, and database applications Pharmacy license

Substitutions

None

Preferred

None

SKILLS

Be able to quickly identify and prioritize essential elements of problem Independently or in a team, be able to identify the root issues and formulate potential solutions Accurately use logic and reasoning in identifying alternate solutions, conclusions or approaches to problems. Potential solutions should be synthesized into presentation, timetable to resolution and appropriate follow up with measurable outcomes

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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