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.

Job Summary:

Reporting to the Manager of Clinical Pharmacy, the Clinical Pharmacist II, Formulary Management is primarily responsible for oversight and management of the Plan’s formularies for Medicaid and Commercial lines of business. The Clinical Pharmacist II, under the supervision of the Manager is also responsible for supporting clinical initiatives that enhance the Plan’s strategic growth objectives.

Our Investment in You:

· Full-time remote work

· Competitive salaries

· Excellent benefits

Key Functions/Responsibilities:

· Participate in the development of formulary management strategies related to specific drug coverage, step therapy protocols, quantity limits, and prior authorization guidelines

· Recommend strategic placement of existing or new drugs on the formulary to maximize benefits based on market trends, rebate opportunities and or clinical guidelines.

· Produce and analyze pharmacy cost trends and support pharmacy benefit design in collaboration with finance and actuarial teams and the PBM partner.

· Annually review Authorization criteria, Quantity limits and formularies to ensure they meet all NCQA/regulatory guidance on both the Medical and Pharmacy Benefits for each line of business.

· Act as a resource for drug information and Pharmacy business support for key internal and external stakeholders

· Review existing clinical policies and ensure clinical practice guideline changes s are reflected.

· Coordinate the activities of the Plan’s Pharmacy and Therapeutics Committee including clinical and financial reviews of individual drugs, drug classes, formulary development, and development of clinical policies and related metrics.

· Assist with clinical pharmacy reporting related to Plan’s contractual requirements.

· Ensure all pharmacy management programs meet applicable NCQA, state and/or contractual utilization management (UM) regulations.

· Ensure that plan formulary is consistent with current standards of quality medical care and medical necessity.

· Present strategies to decrease pharmacy costs to ACO partners and assist in provider detailing strategies to successfully implement recommendations.

· Leads effort in marketing and pharmacy-related member and provider communication materials.

· Assist in the development and maintenance of quality improvement projects, quality metrics, and quality outcome measurements

· Work with internal and external staff to ensure accurate implementation of the Plan’s formularies in accordance with regulatory and/or contractual requirements

· Responsible for ensuring that the Plan’s website is current and accurate including prior authorization criteria, formulary, links, explanations for how to file a request for coverage, etc.

· Other activities as necessary to support utilization management initiatives.

· Regular and reliable attendance is an essential function of the position.

Qualifications:

Education:

· Bachelor of Science in Pharmacy

· Doctor of Pharmacy preferred

· Residency training and Board of Pharmaceutical Specialties (BPS) certification in Pharmacotherapy preferred

Experience:

· 3+ years of prior managed care experience

· Pharmacy & Therapeutics Committee experience

Experience Preferred/Desirable:

· 5+ years of prior managed care experience

Certification or Conditions of Employment:

· Pre-employment background check

· Current unrestricted licensure as a pharmacist in any U.S. state or territory

Competencies, Skills, and Attributes:

· Extensive knowledge of drug products, medical therapeutics, pharmacokinetics, and disease states.

· Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.

· Strong presentation skills and experience with MS PowerPoint

· Demonstrated strong organization and time management skills.

· Able to work in a fast paced environment; ability to multi-task.

· Experience with standard Microsoft Office applications, particularly MS Outlook and MS Word, MS Excel, and other data entry processing applications.

· Strong analytical and clinical problem solving skills.

Working Conditions and Physical Effort:

· Work is normally performed in a typical interior/office work environment.

· No or very limited physical effort required. No or very limited exposure to physical risk.

· Occasional travel (<5%) may be required.

· Face paced office environment.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Required Skills

Required Experience