Capital Rx
Overview
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Formulary Operations Manager - Exchange
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Capital Rx . 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 Manager is responsible for providing operational support for the evaluation, implementation, and maintenance of our standard and custom Commercial and Exchange formularies and utilization management. This individual supports the creation and maintenance of formulary, clinical adjudication list, and utilization management lists, preparation of Exchange JSON formulary submission 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 formulary operations processes. Position Responsibilities
Define, configure, and maintain standard and custom formularies for the Commercial and Health Information Marketplace/Exchange lines of business Provide client-facing strategic and operational support for the configuration, implementation, maintenance, and quality control of custom formularies, drug lists, custom formulary marketing materials, clinical adjudication lists, and utilization management edits Evaluate appropriateness and operationalize custom client formulary and benefit requests within the formulary / adjudication platform Collaborates with teams in a cross-functional environment including, but not limited to; benefit administration, rebate administration, client account management, analytics, software development/product, regulatory/compliance, government programs, member experience, prior authorization operations, and marketing Develop weekly drug product review and formulary recommendations by assessing drug use trends, new drug releases, and review of primary literature Analyze pharmacy cost of care, clinical updates, and coordinate the development of appropriate formulary management programs and utilization management edits Set criteria for medication analysis and coordinate methodology for client requested and regulatory formulary reporting requirements Evaluate drugs/drug classes and make formulary positioning and utilization management recommendations and formulary management strategies and associated adjudication requirements to operationalize Provide cross functional support for claim troubleshooting within the adjudication platform Support comprehensive testing of client formulary and benefit elections Support formulary change processes within URAC/NCQA/SOC guidelines and requirements Support client formulary requests, as required Support quality improvement projects, as required Support the Capital Rx pharmaceutical pipeline, as needed Support Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed Support general business needs and operations, as required 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 EEO Statement
Capital Rx values a diverse workplace and provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type. Salary
Salary Range: $135,000—$145,000 USD Location
Location: Denver, CO
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Join to apply for the
Formulary Operations Manager - Exchange
role at
Capital Rx . 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 Manager is responsible for providing operational support for the evaluation, implementation, and maintenance of our standard and custom Commercial and Exchange formularies and utilization management. This individual supports the creation and maintenance of formulary, clinical adjudication list, and utilization management lists, preparation of Exchange JSON formulary submission 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 formulary operations processes. Position Responsibilities
Define, configure, and maintain standard and custom formularies for the Commercial and Health Information Marketplace/Exchange lines of business Provide client-facing strategic and operational support for the configuration, implementation, maintenance, and quality control of custom formularies, drug lists, custom formulary marketing materials, clinical adjudication lists, and utilization management edits Evaluate appropriateness and operationalize custom client formulary and benefit requests within the formulary / adjudication platform Collaborates with teams in a cross-functional environment including, but not limited to; benefit administration, rebate administration, client account management, analytics, software development/product, regulatory/compliance, government programs, member experience, prior authorization operations, and marketing Develop weekly drug product review and formulary recommendations by assessing drug use trends, new drug releases, and review of primary literature Analyze pharmacy cost of care, clinical updates, and coordinate the development of appropriate formulary management programs and utilization management edits Set criteria for medication analysis and coordinate methodology for client requested and regulatory formulary reporting requirements Evaluate drugs/drug classes and make formulary positioning and utilization management recommendations and formulary management strategies and associated adjudication requirements to operationalize Provide cross functional support for claim troubleshooting within the adjudication platform Support comprehensive testing of client formulary and benefit elections Support formulary change processes within URAC/NCQA/SOC guidelines and requirements Support client formulary requests, as required Support quality improvement projects, as required Support the Capital Rx pharmaceutical pipeline, as needed Support Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed Support general business needs and operations, as required 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 EEO Statement
Capital Rx values a diverse workplace and provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type. Salary
Salary Range: $135,000—$145,000 USD Location
Location: Denver, CO
#J-18808-Ljbffr