It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Reporting to the Director of Clinical Pharmacy, the Pharmacy Clinical Program Manager is responsible for the implementation of clinical formulary updates, including meeting implementation deadlines and ensuring compliance with all accreditation and regulatory requirements. The Pharmacy Clinical Program Manager will develop, manage, maintain, and refine processes to ensure successful completion of all clinical formulary implementations.  This role assumes management and accountability for the day-to-day formulary implementation operations and is the subject matter expert for formulary implementation operations. The Pharmacy Clinical Program Manager may also support benefit implementations as needed.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

KEY FUNCTIONS/RESPONSIBILITIES:

• Manage formulary implementation activities both internally and with pharmacy vendor(s)
• Monitor, distribute, and track policy and criteria updates. Work with clinical subject matter experts (SMEs) within the department and other cross-functional departments to ensure criteria updates are appropriately made, finalized, and implemented
• Approve and finalize all documentation for internal and external publishing, including responsibility for updating system and websites with current applicable policy documentation and ensuring adequate version control
• Submit and maintain tracking of materials sent to external regulatory agencies. Obtain approval where required
• Oversee clinical criteria writing by clinical SMEs and ensure translation into operations for efficient and accurate electronic prior authorization submissions. Supervise writing, editing, and review of criteria operational grids to ensure accuracy before sign-off with vendor
• Create, maintain, and update prior authorization forms
• Working with clinical SMEs responsible for configuration requirements for formulary implementations. Ensure accurate and complete intent documentation both for internal and vendor systems
• Manage and perform quality assurance checks and vendor signoffs throughout implementation
• Develop necessary communications for internal and external stakeholders
• Responsible for non-clinical policy content including updates and revisions
• Lead testing and quality assurance review of formulary configurations to ensure accurate end-to-end implementation. Includes ensuring accurate claims processing, criteria linking in vendor system, and appropriate criteria operational build out to support utilization management (UM) team
• Responsible for compliance with clinical pharmacy controls as required by pharmacy vendor(s), including producing supporting documentation for ongoing oversight and annual audits
• Collaborate cross-functionally with both internal and external partners to support implementations
• Participate on committees and/or cross-functional workgroups as necessary
• Facilitates clinical pharmacy implementation team meetings both internally and with the vendor
• Identifies opportunities to improve existing operational policies and procedures and develops new policies and procedures as necessary
• Provides direction to internal teams on decisions needed as it relates to successful implementation of pharmacy benefit changes, or clinical policies. Works with clinical SMEs on issues requiring clinical collaboration and expertise
• Identifies, communicates, and escalates issues on a timely basis. Independently problem solves programmatic issues and implements appropriate solutions
• Other duties as assigned

QUALIFICATIONS:

• Must be experienced with tools and templates used for tracking, distributing and monitoring work deliverables
• Superior organizational and communications skills, both verbal and written. Experience working within a project team and meeting project deadlines
• Excellent interpersonal skills and communication skills to succeed in a cross-functional, matrixed environment required
• Strong organizational and time management skills, including ability to work independently and prioritize multiple projects and assignments in a fast-paced environment
• Responsible for implementation execution and delivery
• Process-oriented and can accomplish tactical deliverables and meeting deadlines
• Flexible, team-player approach to goal setting and attainment
• Self-motivating, able to assume responsibility and work autonomously in a professional manner
• Demonstrated strength in analysis, identification of problems and issue resolution
• Must be results and detail oriented

EDUCATION & EXPERIENCE:

• Bachelor’s degree, preferred, in project administration or the equivalent of 3+ years in administrative/project management positions
• Experience in a managed care setting, either from the provider, the payer, or the PBM side of the industry, is preferred
• Proficiency in standard computational office-suite applications, including Word, Excel, PowerPoint, SharePoint, and Outlook required
• Previous experience with PolicyTech is preferred

WORKING CONDITIONS AND PHYSICAL EFFORT:

• Occasional travel (<5%) may be required

ABOUT WELLSENSE

WellSense Health Plan is a nonprofit health insurance company serving more than 440,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.

*WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.

Required Skills Required Experience