Manager, Medicare Part D Formulary

Arizona, Utah

Job Description

This position will support all clinical aspects related to administration and operations of the strategic business unit(s) program surrounding Medicare Part D. The individual will work with internal and external partners to maintain compliance with Centers for Medicare & Medicaid Services (CMS) guidance and ongoing prospective and retrospective analysis of clinical attributes related to formulary and plan design, member health outcomes, and pharmacy delivery models. Will have problem solving and critical thinking skills encompassing the multifaceted delivery of the Medicare Part D benefit. Will work in a team environment to garner and manage the internal resources and communicate through all the strategy of the organization.
  • Ability to read, interpret, and operationalize Medicare Part D guidance and ability to understand how various aspects of the guidance is interdependent and related. 
  • Assist leadership in review and interpretation of all existing and new Health Plan Management System (HPMS) guidance from CMS re: clinical elements of the Part D program (e.g., transition, protected class drugs, formulary changes, ESRD, Hospice, etc.)
  • Responsible for providing support in administering formulary (including transition) and oversight of adherence and retrospective Drug Utilization Review (DUR).
  • Works with internal partners to operationalize the administration of the formulary, benefit and transition fill.
  • Responsible for providing support to develop, monitor, improve operational controls related to clinical aspects of the Part D program – particularly Formulary Administration and Coverage Determinations, Appeals and Grievances.
  • Works with internal partners to develop and support claims monitoring (paid and rejected) criteria related to clinical aspects of the Part D benefit; reviews claims daily to flag suspect items for detailed review with SMEs.
  • Works with department leadership and the compliance team and medical director to develop, maintain and provide clinical leadership in the development of new methodology and technology that allows SBU to stay on the cutting edge of high quality, pharmacy benefits management.
  • Operationalizes and monitors clinical efforts pertaining to reporting (maintenance and ad hoc), adjudication, Coverage Determinations and Appeals.
  • Provides support for the annual Part D bid as it pertains to formulary definition.
  • Participates in internal and external audits.
  • Ensures all programs are of the highest clinical quality and integrity and provides clinical oversight to all clinical areas within the department.
  • Problem solving and critical thinking driving multidisciplinary efforts and planning.
  • Oversight of downstream providers to ensure delivery of services according to contractual agreements held between Magellan and vendor.
  • Participates in the development of strategic and operational goals and plans for the growth and ongoing clinical operations of SBU.

General Job Information

Title

Manager, Medicare Part D Formulary

Grade

31

Job Family

Pharmacy Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

1/21/2020

Date Requisition Created

1/21/2020

Work Experience

Medicare Part D (MedD), PBM (Pharmacy Benefit Management), Pharmacy

Education

Bachelors: Pharmacy (Required)

License and Certifications - Required

RPH - Registered Pharmacist - Pharmacy

License and Certifications - Preferred

Other Job Requirements

Responsibilities

Medicare Acumen.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

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