Clinical Program Senior Manager - Hybrid (Multiple Locations)

Role Summary:

This position is responsible for the oversite of implementation activities related to formulary management and utilization management on the pharmacy and medical benefit to ensure affordability targets are achieved, compliance with regulatory requirements, and business strategy intent is met.

Affordability solutions encompass activities that include utilization management edits at point of service, preferred drug list strategy, retrospective utilization review, risk management review and condition-specific interventions.

The position works closely with matrix partners across the medical organization, PBM partners, Contracting, Pharmacy pricing/finance, Clinical Operations, Coverage Policy Unit, Pharmacy and Medical client facing partners, Pharmacy product, Analytics, Compliance, Legal, and Specialty Pharmacy.

This position is responsible for the management of the clinical pharmacists who work to support formulary management activities as well as oversight of key functions that the clinical pharmacists are aligned to.

Responsibilities:


* Lead a team of clinical pharmacists with day-to-day formulary management activities


* Execute implementation strategies for major specialty and non-specialty drug classes across the pharmacy and medical benefit, including designing and implementing specific actions and workflows to drive affordability and meet quarterly targets


* Evaluate the success of current utilization management programs to determine areas of enhancement


* Monitor market share leakage for non-formulary drugs and implement strategies to address leakage and waste in the commercial population


* Provide education and training for clinical teams (Pharmacy Service Center, Home Delivery, Specialty Pharmacy, Medical Management) to communicate clinical strategy and actions and assure consistent execution of class strategy


* Responsible for the oversight of the review and audit of all Health Plan Value Assessment Committee recommendations/decisions to ensure all formularies are compliant with P&T guidelines


* Responsible for the oversight of all state audits and updated regulatory requirements to ensure that the formulary management process and decisions of the Health Plan Value Assessment Committee are in line with state and federal regulations


* Responsible for post-implementation affordability monitoring related to clinical issues resulting in loss of affordability


* Responsible for the oversight of the new drug management process for pharmacy and medical drugs


* Responsible for the oversight and monitoring of clinical research tasks to support the formulary strategy leads


* Responsible for the oversight of periodic auditing and maintenance of existing drug lists related to compliance/legal mandates, product, and back-end formulary maintenance logic


* Responsible for engaging with matrix partners to identify potential impacts to formulary strategies

Qualifications:
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