Consultant, Formulary Administration

4 weeks ago

Bloomington, United States HealthPartners Full time
HealthPartners is hiring Formulary Administration Consultant.

This position is responsible for the formulary management of Regulated Products (Medicare, State Public Programs, Exchange, and Federal Employees Programs).

The consultant will assist in the development, maintenance, and communication of all formularies and covered products.

Areas of focus include Regulated Products formulary and benefits; Fraud, Waste and Abuse (FWA) Management, Marketing and Member Materials, Compliance and Audit Support.

The position also supports Pharmacy Department initiatives.

MINIMUM QUALIFICATIONS:

Education, Experience or Equivalent Combination:

Minimum of two years of experience working in a managed care pharmacy or clinical pharmacy setting or completion of a managed care pharmacy residency program.


Licensure/ Registration/ Certification:
Licensed Pharmacist in Minnesota.

Knowledge, Skills, and Abilities:
Familiar with formulary maintenance. Familiar with the development of drug coverage policies and utilization management programs. Demonstrated skill in problem solving, planning, organizing and time management.

Demonstrated skill in effective project management including use of project planning and tracing tools, achievable goals, objectives, and timelines, and innovative use of resources.

Excellent verbal and written communication skills. Excellent attention to detail and accuracy. Ability to manage multiple projects simultaneously. Ability to solve problems with minimal direction. Self-motivated with critical thinking ability and ability to work independently. Must be able to establish and maintain effective, courteous, and confidential relationships with coworkers, staff, employer groups, and members.

PREFERRED QUALIFICATIONS:

Knowledge, Skills, and Abilities:
Pharmacy Benefit Management experience including formulary and utilization management experience. Medicare Part D experience. Health Insurance Exchange experience. Experience with Minnesota State Public Programs (e.g., Medicaid)

Essential Duties:
1.

Leads and carries out activities related to the annual development and submission of formularies for Exchange, State Public Programs and/or Medicare lines of business.


2.
Serves as the Pharmacy formulary subject matter expert and advisor for a specific product line.

3.
Reviews new drugs to the market and recommends specific formulary and UM assignments.

4.
Works with actuary team to develop market competitive and member friendly formulary.

5.

Tracks coverage change decisions made by the Pharmacy & Therapeutics Committee and ensures changes are implemented in accordance with internal business rules and statutory and regulatory requirements.


6.
Supports clinical program updates.

7.
Understands drug product information to support oversight and monitoring of PBM activities.

8.
Assists with communications to both members and providers who are affected by drug coverage changes.

9.

Assists other pharmacy personnel (such as Formulary Administration Coordinators and Configuration Services Analysts) in all other areas of formulary and benefit maintenance as needed.


10.

Maintains a thorough and comprehensive understanding of state and federal requirements (statutory and regulatory) and accreditation standards (Commercial, Exchange, State Public Programs, and/or Medicare).


11.
When problems are identified, assists with corrective action plan documentation and issue resolution.

12.
Reviews written department materials and policies and procedures, revising them as needed to provide uniformity and usability.

13.
Supports regulatory and accreditation audits including formulary and benefit related questions and submission of documentation as needed.

14.
Supports decision trees development and maintenance.

15.
Assists in development and management of unique pharmacy coverage programs and product offerings.

16.
Works with the HealthPartners PBM through data analytics to identify pharmacy substantiated or suspicious activities of FWA.

17.
Uses medical and pharmacy claims data to identify outlier prescribers of opioids with unusually high volume and dosages. Works with provider contracting to determine appropriate prescribing practices.

18.
Analyzes CMS-provided FWA drug tend reports and proposes appropriate actions.


We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

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