Pharmacist, Principal

Your Role The Formulary Management team leads the development and maintenance of multiple formularies to support competitive health plan products, manage cost-of-healthcare, and meet regulatory requirements for all lines of business including Commercial Large Group, Commercial Small Group, Individual/Family plan, and Medicare. The Pharmacist, Principal will report to the Senior Manager of Formulary Management. In this role you will collaborate with cross-functional areas to support Medicare formulary and utilization management development, regulatory submissions, and operations. You will identify and implement opportunities to manage cost-of-healthcare, ensure compliance with Medicare regulatory requirements, and improve quality through formulary and utilization management optimization. You will also be involved in implementation and validation of Medicare formularies and utilization management on the claims adjudication system and the formulary management system. You will act as subject matter expert to represent the Formulary Management team during state and federal audits, and you may be asked to support or lead special projects.Your Work In this role, you will: Develop, analyze & monitor prescription drugs, medical claims, and program data to identify opportunities to improve quality, recommend cost of healthcare opportunities that are compliant with the state and federal formulary regulations, and monitor/report performance and outcomes Develop recommendations for drug formularies, medication coverage policies, and pharmacy benefits based on clinical, regulatory, and business requirements Review and recommend formulary changes based on guidelines, claims utilization, or prior authorization data Develop project proposals for identified opportunities and support implementation Serve as a Blue Shield of California (BSC) Pharmacy Services contact and subject matter expert to stakeholders, and manage external relationships (vendors, clients) related to assigned work Support the operational implementation and maintenance of formulary, including accurate installation of drug formularies and utilization management edits for claims adjudication, in accordance with regulatory and business rules for Medicare line of business Review member material and ensure accuracy of formulary-related collateral documents and websites Support and assist in regulatory audits and review of regulatory memo/legislation  Coordinate activities of the program area with other business units and monitor operational statistics to ensure all respective accreditation, regulatory, and compliance requirements are met Make improvements and modifications to operating policies to enhance performance of the department Communicate with parties external to the organization, which may include customers or vendors as well as leadership Explain policies, practices, and procedures of the Medicare Formulary Management to others within the organization. May also influence decisions, work to justify and gain alignment from other parties involved on Formulary management practices Provide guidance, assistance, coaching and training to the team or other employees as assigned Provide direction for the team, review work results, and focus on maintaining steady workflow and productivity and resolving operational decisions Precept Pharmacy Practice Residents Perform other projects and duties as assigned Your Knowledge and Experience Requires a Doctor of Pharmacy (PharmD) degree Requires a currently active and unrestricted California Registered Pharmacist (RPh) license Requires 4 years of experience in clinical pharmacy  Strong knowledge of Medicare Formulary and Utilization Management regulatory requirements  Experience with Medicare Part B drug coverage rules, including National and Local Coverage Determination guidelines (NCD/LCD)  Strong independent judgement, critical and analytical thinking, and problem-solving skills Thorough knowledge of managed care and pharmacy benefit management practices, including utilization management Strong background in pharmacy operations working with Pharmacy Benefit Management vendor claims adjudication Familiarity with Medispan drug files  Thorough clinical and regulatory knowledge regarding therapeutic use of drugs Excellent oral and written communication skills Ability to multi-task, prioritize, and deliver in a demanding and constantly changing corporate environment Advanced skills and experience with Microsoft related software applications   Pay Range: The pay range for this role is: $145,970.00 to $218,900.00 for California. Note: Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

Created: 2025-02-13