[Remote] Senior Clinical Pharmacist - Medicare Formulary Strategy

Note: The job is a remote job and is open to candidates in USA. Blue Cross NC is seeking a Senior Clinical Pharmacist to join their team in the Medicare Formulary Strategy department. This role involves supporting the design, development, and execution of formulary strategies for Medicare, ensuring compliance with CMS regulations while collaborating with various cross-functional teams.

Responsibilities

• Participate in the annual Medicare formulary planning process from kick-off through CMS submission and final approval
• Assist with development and execution of Medicare formulary strategies that balance clinical efficacy, cost-effectiveness, compliance, and competitive positioning
• Conduct competitive analyses, assess rebate and lowest net-cost opportunities, evaluate customer cohort profitability analyses, and product-specific strategies aligned with evolving product and market needs
• Support the development of custom formularies tailored to the needs of each Medicare product
• Research market trends, evaluate competitive positioning, and assess the regulatory landscape to guide Medicare formulary strategies
• Participate in the Pharmacy & Therapeutics (P&T) and Business Assessment Committee, ensuring evidence-based decision-making and CMS compliance
• Partner with Actuarial, Finance, Clinical and Product teams to model financial scenarios, assess member impact, and evaluate competitive positioning
• Conduct ongoing and ad hoc reviews focused on specialty tiers, utilization management, STARS performance, and high-cost/high-trend drugs
• Ensure P&T compliance with CMS regulatory standards
• Work with PBM and internal partners to ensure CMS approval of formularies
• Monitor emerging drug trends, competitive market dynamics, and utilization patterns to proactively identify opportunities or risks
• Partner with Actuary and Data & Analytics teams to conduct analyses of formulary performance, including customer cohort profitability, trend tracking, UM performance, and tier exception reviews
• Participate in refining strategy based on market intelligence and performance insights

Skills

• Bachelor's degree or advanced degree
• 5+ years of experience in related field
• In lieu of degree, 7+ years of experience in related field
• Licensed pharmacist or eligible for licensure in North Carolina
• BA/BS in Pharmacy and a minimum of 5 years of Medicare managed care pharmacy experience; or any combination of education and experience, which would provide an equivalent background
• Advance degree preferred (PharmD, MBA, MPH, or equivalent)
• Minimum of 5 years of experience in Medicare Part D & B formulary management with a Medicare plan sponsor or pharmacy benefit manager (PBM)
• Strong understanding of Medicare Part D & B formulary requirements and regulatory guidance
• Strong understanding of Medicare regulatory requirements for Pharmacy and Therapeutics Committees
• Strong analytical, data interpretation, and trend management skills
• Knowledge of Part D Stars measures and their application in formulary strategy
• Excellent communication and presentation skills, with the ability to engage leadership and cross-functional stakeholders
• Strategic planning and execution within the Medicare environment
• Ability to synthesize clinical, financial, and regulatory insights into actionable strategies
• Strong analytical and problem-solving abilities
• Proven project management skills, including timeline development, prioritization, and cross-functional coordination

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution

Company Overview

• It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. It was founded in 1933, and is headquartered in Durham, North Carolina, USA, with a workforce of 5001-10000 employees. Its website is https://www.bluecrossnc.com/.

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