Operations Specialist, Senior

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 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 efforts with formulary for pharmacy claim adjudicator and other vendors to ensure maintenance, validation, and audits are compliant with business needs. You will support in the development and maintenance of the formularies for all Blue Shield lines of business - Commercial, Exchange, and Medicare.

This role is responsible for supporting day-to-day operations, maintaining of formulary and drug list databases, supporting P&T materials and documentation, maintaining desk-level procedures as well as job aids, and creating reports. The Operations Specialist, Senior will collaborate with the pharmacy claim adjudicator, analytics, benefits and claims, Pharmacy Market Experience, Compliance, prior authorization, and customer services departments to communicate formulary and utilization management changes, formulary intent, and to ensure that formulary decisions are implemented in accordance with 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 Blue Shield of California (or similar 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