Position Purpose: Define and develop standard and custom formularies for complex or specialized medications for assigned plan
Develop clinical criteria for review of complex or specialized medications, recommend plan design changes and communicate recommendations to clients
Monitor and review prior authorization/appeal requests for complex or specialized medications
Develop and design clinical edits to adjudicate claims and enhance drug utilization
Analyze pharmacy cost of care, trends, and coordinate the development of appropriate use protocols and guidelines
Set criteria for medication analysis, coordinate reports to clients, meet regulatory reporting requirements for drug utilization review and fraud and abuse reporting
Develop and implement medication therapy management programs.
Evaluate program performance, recommend changes and ensure successful implementation of changes
Ensure and evaluate quality controls and implement opportunities for performance improvement
Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Provide clinical guidance and support to various departments and address clinical related questions
Define, develop, implement and maintain standard and custom formularies and/or clinical edits and implement and maintain regulator required formularies and/or clinical edits, as required by your manager
Provide formulary and/or clinical edit subject matter expertise, guidance and support to Formulary and Benefit Management team, various departments and plan pharmacy departments
For Clinical Programs (Operational Excellence):
Support ongoing evaluation of clinical program initiatives promoting quality, safety and cost of care opportunity
Support oversight, development and expansion of clinical pharmacy programs and initiatives by assessing utilization trends and relevant data and literature
Analyze pharmacy data and trends needed to drive positive member outcomes
Ensure and develop strategic relationships supporting organizational strategic initiatives
Performs other duties as assigned
Complies with all policies and standards
Education/Experience: Bachelor’s degree or advanced degree (Pharm.D., M.S.) in pharmacy. 4+ years of mail order, retail, hospital, managed care pharmacy experience or pharmacy residency program experience.
Licenses/Certifications: Current state’s Pharmacist license with no restrictions
May be required to obtain additional state licensure based on business needs
For Clinical Programs (Operational Excellence): Support clinical program outcome analysis and evaluation across populations of patients in order to improve disease state outcomes and improve medication related safety. Support and assist in the development and analysis of various clinical programs to drive strategic initiatives across lines of business including Commercial, Medicaid, Medicare Part D and the Health Insurance Marketplace.
Pay Range: $107,700.00 - $199,300.00 per year
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law , including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal…