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.

What You'll Do

Formulary Development & Strategy

• 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.

Governance & Review

• 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.

Market Monitoring & Trends

• 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.

What You Bring

• 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.

Preferred Skills, Capabilities and Experience

• 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 (PharmD, 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.

What You’ll Get

• 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 health and wellness programs

• Parental leave and support plus adoption and surrogacy assistance

• Career development programs and tuition reimbursement for continued education

• 401k match including an annual company contribution

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets,  licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. 

*Based on annual corporate goal achievement and individual performance.
 

$118,691.00 - $189,906.00

Skills

Clinical Knowledge, Clinical Pharmacy, Clinical Practice Management, Clinical Programs, Clinical Review, Clinical Trials Operations, Medicare, Medicare Part D, Medication Therapy Management, Nursing Practice, Patient Care Coordination, Pharmaceutical Medical Affairs, Pharmacy, Pharmacy Compliance, Pharmacy Management, Pharmacy Operations

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