About SCAN
SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 277,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.
The Job
This position will play an important role in providing operational support for evaluation, implementation, and maintenance of Medicare Part D Formulary and Utilization Management, review of new drugs with the Pharmacy & Therapeutics Subcommittee/Committee. This position is accountable for ensuring regulatory compliance with respect to the Medicare Part D formulary submissions to CMS, pharmacy benefits, formulary and transition program implementation with PBM, website content for all business lines, pharmacy network and CMS’s Part D regulatory audits. The Clinical Pharmacist stays abreast of pharmacy, PBM, payer industry changes, pipeline, drug trends, best practices, and CMS’s rules and regulations, including Inflation Reduction Act. The role requires strong cross functional collaboration and communication skills, and an understanding of Medicate Part D formulary and Utilization Management (UM) processes.
You Will
Ensures regulatory compliance with P&T operations, Formulary & Benefit Administration, Transition Programs, annual Part D bid submission process, pharmacy-related member and other stakeholders’ communications and marketing materials, including member formulary drug list, website content, trainings, pharmacy network and CMS’s regulatory audits:
Produces, maintains, and implements Part D Formulary, Prior Authorization criteria, Step Therapy criteria, Supplemental files, and clinical rules in accordance with CMS requirements on monthly and annual basis and submits these files to CMS.
Develops and maintains formulary exception criteria.
Evaluates and reviews new drugs/biosimilar with the Pharmacy & Therapeutics Subcommittee/Committee within 90-180 days of being marketed and makes Formulary and UM recommendations based on the clinical appropriateness, cost analysis and CMS guidelines.
Works in collaboration with Medical Directors to evaluate and analyze treatment protocols and procedures related to the SCAN Health Plan formulary, at least annually.
Provides CMS Part D regulatory audit support for respective areas.
Produces member communications and marketing materials, within internally determined timeframes, with accuracy and in accordance with CMS marketing guidelines. Partners with Marketing, Compliance and Member Services and vendors, as needed. Prepares training materials.
Maintains on-line comprehensive formulary on a monthly basis on accordance with CMS requirements.
Assists with Formulary and UM modeling for the annual Formulary and BID submissions to CMS.
Reviews accuracy of the Formulary, UM files, and Pharmacy Benefits for the annual BID submission to CMS.
Prepares Formulary/Pharmacy Benefits Industry Analysis annually.
Complies and implements Inflation Reduction Act requirements with PBM and CMS Innovation Programs, as needed.
Monitors drug pipeline, drug trends, and payer industry changes throughout the year to identify potentially high Part D impact drugs. Manages Part B drug trend and value-based opportunities.
Oversees PBM operations in the areas of Formulary, Opioid Safety Edits, Pharmacy Benefits, Transition Programs, Prescriber Enrollment Requirements and Pharmacy Network Implementation.
Ensures AEP and 1/1 readiness and assists in training of other departments.
Serves as the clinical subject matter expert for respective areas, providing guidance as needed.
Maintains current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance and implementing changes to maintain compliance.
Manages multiple deadlines and completes projects with 100% accuracy.
Maintains professional and technical knowledge by conducting research and by attending educational and technological workshops. This position requires contributions to team efforts by accomplishing and sharing related results with other staff.
Contributes to team efforts by accomplishing related results as needed.
Collaborates with other team members within the Pharmacy Department; collaborates with other SCAN departments: Compliance, Marketing, HCI, Product, Member Services to support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.
Your Qualifications
Pharm. D. Degree required
Registered Pharmacy Licensure required within 6 months of hire
Residency Program in Managed Care, Pharmacy Practice, Drug Information or Geriatric Pharmacy, preferred.
Managed care experience at the PBM, health plan or medical group, required.
Medicare Part D experience in formulary management, required.
Excellent verbal/written communication, interpersonal, presentation, customer, problem-solving and computer skills, required.
Effective utilization of information systems required.
What's in it for you?
We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.
SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
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