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JOB SUMMARY
This job works in a team-oriented environment monitoring FDA-approvals, drug manufacturer pipelines, and assessing drug utilization reports, to develop and execute the the organization's drug formulary, and develop pharmacy utilization management policies, and maintains compliance with federal, state, and other mandates. The incumbent may write drug monographs for committee review; develop and implement the organization's management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling, pharmacy policy review and development and/or review of member specific information to improve individual outcomes. The incumbent develops and implements physician, pharmacy, account, and member educational initiatives that promote the organization’s formularies, utilization management programs, and participates on cross-functional committees to develop and implement clinical and operational initiatives, working in close collaboration with matrix partners and stakeholders across the organization. The incumbent may interact with pharmaceutical manufacturers, the pharmacy benefit manager, and/or strategic partners to implement clinical formulary and utilization management strategies. The incumbent may provide guidance to more junior team members, participate in evaluating, implementing, and monitoring pharmacy benefit-focused federal and state legislation, develop, execute, and monitor pharmacy-specific strategic initiatives, and/or present recommendations to leadership.
ESSENTIAL RESPONSIBILITIES
Formulary & Utilization Management Strategy & Development: May lead Highmark’s evidence-based medicine drug evaluation program supporting Highmark’s formulary and utilization management (UM) and/or pharmacy program strategy. Develop pharmacy formulary and UM program initiatives supporting Highmark Enterprise Customer Value Creation (C2V) program savings goals. Assist in the development of drug formularies by monitoring FDA-approvals and drug manufacturer pipelines, assessing drug utilization reports, and writing drug monographs for Pharmacy & Therapeutics Committee review, as applicable. Assist in the development and implementation of utilization management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step therapy edits, generic sampling, pharmacy policy review and development and/or review of member specific information to improve individual outcomes.
Regulatory Compliance & Oversight: Execute Highmark’s Pharmacy & Therapeutics Committee charter and program compliance in accordance with regulatory standards. Support regulatory compliance related to the organization’s prescription drug benefit, formularies, and pharmacy utilization management policies. Manage formulary administration and oversight, ensuring all aspects of work adhere to applicable state and federal requirements. May represent Highmark in applicable state or federal audits.
Strategic Collaboration & Analytics: May partner with internal analytics organization and external pharmacy vendors (as applicable) to generate real-world evidence insights to support of Highmark pharmacy strategy. Participate in cross-functional committees to develop and implement clinical and operational initiatives within the organization with focus on pharmacy.
Quality Assurance & Review: Serve as a peer-reviewer of medication reviews, pharmacy utilization management policies, and other strategy deliverables, as applicable.
Education & Communication: Develop and implement physician, pharmacy, client, and member educational initiatives that promote the organization's pharmacy strategies including formularies, utilization management programs, and other pharmacy programs.
Project Management & Process Improvement: Identify and assist in managing department process improvements to maximize overall efficiencies. Manage individual projects for timely review with leadership.
Team Guidance & Mentorship: Provide guidance to more junior team members.
Other duties as assigned or requested.
EXPERIENCE
Required
5 years of related, progressive experience in the pharmacy area of specialization OR completion of an accredited PGY-1 Managed Care Pharmacy Residency Program plus 2 additional years of related, progressive experience in the pharmacy area of specialization
Preferred
Progressive experience in pharmacy strategy, formulary administration, pharmacy program or product development within a health system, health plan, or pharmacy benefit manager setting
SKILLS
An understanding of managed care pharmacy principles and practices is essential
Demonstration of strong verbal and written communication skills, as well as proficiency in the use of computer-based data processing
Microsoft Office products, and database applications
Be able to quickly identify and prioritize essential elements of problem
Independently or in a team, be able to identify the root issues and formulate potential solutions
EDUCATION
Required
Bachelor of Science in Pharmacy or a Doctor of Pharmacy degree
Preferred
None
LICENSES or CERTIFICATIONS
Required
Registered Pharmacist (Non-State Specific)
Preferred
Board Certified Pharmacotherapy Specialist
Board Certified Geriatric Pharmacist
Language (Other than English):
None
Travel Required:
Less than 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-Based or Remote Position
Physical work site required
Frequently
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$118,400.00Pay Range Maximum:
$196,800.00Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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