Operations Specialist, Senior

Your Role

The Formulary Management team leads the maintenance of multiple formularies to support competitive health plan products and meet regulatory requirements for all lines of business including Commercial Large Group, Commercial Small Group, Individual/Family plan, and Medicare. The Operations Specialist, Senior will report to the Senior Manager of Formulary Management. In this role you will be a subject matter expert who will lead formulary implementation with the pharmacy claim adjudicator and other vendors to ensure maintenance, validation, and audits are compliant with business needs.

This role is responsible for supporting day-to-day operations, maintaining of formulary and drug list databases, maintaining desk-level procedures as well as job aids, and creating reports. The Operations Specialist, Senior will collaborate cross functionally with the pharmacy claim adjudicator, analytics, benefits and claims, communications, compliance, prior authorization, and customer services departments to communicate formulary and utilization management changes, formulary configuration, and to ensure that formulary decisions are implemented in accordance with health plan client business rules and regulatory requirements.

Your Knowledge and Experience

• Requires a college degree or equivalent experience

• Requires at least 5 years of prior relevant experience within Pharmacy Services (e.g., claims, customer service, benefits, prior authorization, formulary)

• Experience working with Pharmacy Benefit Management systems or vendors

• Knowledge of Pharmacy Benefit design and Formulary configuration; knowledge of health care organization pharmacy configuration is preferred

• Requires California Pharmacy Technician Certification

• Requires strong skills in standard Microsoft Office applications (e.g., Excel, Word, Outlook)

• Strong coordination and interpersonal skills working in a matrixed environment with multiple stakeholders

• Familiarity with Medispan drug files is preferred

• Experience in practical project management is preferred

• Demonstrated experienced identifying and resolving complex problems related to automated systems and operations within functional area

• Broad knowledge of technical and operational practices of formulary decision documentation, regulatory submission, and implementation in the claims processing system is preferred

• Knowledge of Medicare Part D and Commercial formularies requirements is preferred