Your Role

The Formulary Management team leads the development and maintenance of multiple formularies to support competitive health plan products, manage cost-of-healthcare, and meet regulatory requirements for all lines of business including Commercial Large Group, Commercial Small Group, Individual/Family plan, and Medicare. The Operations Specialist, Experienced will report to the Operations, Supervisor. In this role you will be a subject matter expert that will lead efforts with formulary and pharmacy benefits manager (PBM) to ensure maintenance, validation, and audits are compliant with business needs. You will support in the development and maintenance of the formularies for all Blue Shield lines of business - Commercial, Exchange, and Medicare. This role is responsible for supporting day-to-day operations, maintenance of databases, some P&T materials and documentation, policies and procedures as well as desk-level procedures. The Operations Specialist, Experienced will collaborate with the PBM vendor, analytics, benefits and claims, Pharmacy Market Experience, Medicare compliance, prior authorization, and customer services departments to communicate formulary and utilization management changes, formulary intent, and to ensure that formulary decisions are implemented in accordance with business rules and regulatory requirements.

Your Work

In this role, you will:

• Act as subject matter expert and review operational workflows, identifying problems and develops improvements, modifications, and enhancements; identify technical formulary issues that would prevent or delay CMS approval of BSC formularies; notify appropriate managers of Medicare formulary issue requiring immediate attention for resolution; determine appropriate workflow required for maintaining formulary decisions
• Maintain formulary databases and associated utilization management edits related to weekly drug updates and required for business operations related to Formulary Management for Commercial, Exchange, and Medicare lines of business. Review systems and applications and recommends system edits/changes as needed
• Develop and evaluates tools and materials that enhance operating efficiency and accuracy related to Formulary management, both internal to the team and across the department and in conjunction with external vendors used to manage and maintain the formulary for all lines of business
• Develop and transmits the documentation required to notify CMS of formulary, prior authorization criteria, and step therapy criteria changes
• Develop required Commercial and Medicare printed formulary documents and works with the Pharmacy Communications, Medicare Marketing, and Web/Mobile teams to make these documents available in print and online. Assist with updating content and web posting requirements including drug coverage requirements such as prior authorization and step therapy criteria
• Participate as a subject matter expert in the development of written guidelines and documents desk level procedures and policy and procedures
• Maintain and adheres to regulatory requirements for Department of Managed Health Care (DMHC), Exchange, and Medicare as subject matter expert related to formulary submissions, notification to internal/external stakeholders of changes to utilization management edits, and generation/distribution of collateral, including letters, websites, and formulary PDFs
• Validate claims to ensure formulary implementation is consistent with formulary decisions and regulatory requirements
• Coordinates operational implementation of formulary decisions as subject matter expert with internal teams (eg, Drug Utilization Review, Pharmacy Benefit & Claims, Pharmacy Market Experience) and external teams (Pharmacy Benefits Adjudicator)
• Act as subject matter expert of formulary operational workflows for implementing formulary decisions in compliance with state and federal regulations and audits
• Occasional business travel required

Your Knowledge and Experience

• Requires a bachelor's degree, or equivalent experience.
• Requires at least 5 years of prior relevant experience within Pharmacy Services (eg, claims, customer service, benefits, prior authorization, formulary)
• California Pharmacy Technician Certification preferred
• Strong skills in standard Microsoft Office applications (eg, Excel, Word, Outlook, Access)
• Strong coordination and interpersonal skills working in a matrixed environment with multiple stakeholders
• Requires ability to identify and resolve complex problems related to automated systems and operations within functional area
• Requires experience in practical project management
• Broad knowledge of technical and operational practices of formulary decision documentation, regulatory submission, and implementation in the claims processing system is preferred
• Familiarity with Medispan drug files is preferred
• Knowledge of Medicare Part D and Commercial formularies is preferred

Pay Range:

The pay range for this role is: $75,680.00 to $113,520.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

About the Company:
Blue Shield of California