Formulary Operations Pharmacist – Medicare

About Capital Rx 

Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi®, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.

Position Summary:

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.

Position Responsibilities:

• Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelines
• Support development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug lists
• Lead and support preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, and utilization management criteria
• Evaluate drugs/drug classes, make formulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalize
• Evaluate appropriateness of and operationalize custom client formulary and benefit change requests within the formulary and adjudication platform
• Support comprehensive testing of client formulary and benefit elections
• Provide cross functional support for claim troubleshooting within the adjudication platform
• Monitor and analyze regulatory and legislative requirements for Medicare
• Support development of project plans to meet new CMS requirements, and support cross functional teams with implementation of programs to meet requirements
• Lead formulary change processes within URAC/NCQA/CMS guidelines
• Pharmacy and Therapeutics (P&T) Committee participation as an ad hoc member
• Conduct formulary reviews and develop drug monographs based on a rotation of clinical pharmacists
• Maintain and update the Capital Rx pharmaceutical pipeline, as needed
• Develop clinical criteria for review as needed
• Support CMS formulary administration audits
• Support quality improvement projects as needed
• Support Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed
• Support general business needs and operations, as needed
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Minimum Qualifications:

• Doctor of Pharmacy (PharmD) Degree from an accredited institution, with record of strong academic performance
• Current, unrestricted registered pharmacist license(s)
• Residency/fellowship preferred
• 2-3 years of formulary experience working for a health plan or PBM preferred
• 2-3 years of Medicare experience preferred
• Knowledge of formulary development and maintenance processes
• Knowledge of highly managed specialty medications/strategy
• Knowledge of rebate and financial implications of formulary strategies
• Experience working with large datasets preferred
• Ability to independently identify, research, and resolve issues
• Ability to balance multiple complex projects simultaneously
• Ability to work extended hours, weekends, and holidays consistent with industry demands
• Exceptional written and verbal communication skills
• Extremely flexible, highly organized, and able to shift priorities easily
• Attention to detail & commitment to delivering high quality work product
• Microsoft office suite with emphasis on Microsoft excel proficiency required

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.