Job Description
We're seeking a Medicare Formulary Strategy Manager to lead the design, development, and execution of formulary strategies (Part D and Part B) for all Medicare formularies, including MAPD (HMO, PPO, DSNP), PDP and EGWP. This role requires close collaboration with cross-functional partners-including Medicare Pharmacy Operations, UM Operations, Compliance, STARS, Medical Management, Actuary, Product, Clinical, and Finance teams to ensure formularies are clinically appropriate, cost-effective, competitive in the marketplace, and compliant with CMS regulations.
How you will make an impact:
Formulary Development & Strategy
- Leads the annual Medicare formulary planning process from kick-off through CMS submission and final approval.
- Develops and executes Medicare formulary strategies that balance clinical efficacy, cost-effectiveness, compliance, and competitive positioning.
- Conducts competitive analyses, assesses rebate and lowest net-cost opportunities, evaluates customer cohort profitability analyses, and product-specific strategies aligned with evolving product and market needs.
- Supports the development of custom formularies tailored to the needs of each Medicare product.
- Researches market trends, evaluates competitive positioning, and assesses the regulatory landscape to guide Medicare formulary strategies.
Governance & Review
- Participates in the Pharmacy & Therapeutics (P&T) and Business Assessment Committee, ensuring evidence-based decision-making and CMS compliance.
- Partners with Actuarial, Finance, Clinical and Product teams to model financial scenarios, assess member impact, and evaluate competitive positioning.
- Conducts ongoing and ad hoc reviews focused on specialty tiers, utilization management, STARS performance, and high-cost/high-trend drugs.
- Ensures P&T compliance with CMS regulatory standards
- Works with PBM and internal partners to ensure CMS approval of formularies.
Market Monitoring & Trends
- Monitors emerging drug trends, competitive market dynamics, and utilization patterns to proactively identify opportunities or risks.
- Partners with Actuary and Data & Analytics teams to conduct analyses of formulary performance, including customer cohort profitability, trend tracking, UM performance, and tier exception reviews.
- Refines strategy based on market intelligence and performance insights.
What You Bring
Bachelor's degree or advanced degree (where required)
8+ years of experience in related field.
In lieu of degree, 10+ years of experience in related field.
Current valid active unrestricted state(s) RPH license required.
Bonus Points (preferred qualifications)
- A minimum of 5 years of Medicare managed care pharmacy experience; or any combination of education and experience, which would provide an equivalent background.
- Advance degree preferred (PharmD, MBA, MPH, or equivalent).
- Minimum of 5 years of experience in Medicare Part D & B formulary management with a Medicare plan sponsor or pharmacy benefit manager (PBM).
- Strong understanding of Medicare Part D & B formulary requirements and regulatory guidance.
- Strong understanding of Medicare regulatory requirements for Pharmacy and Therapeutics Committees
- Strong analytical, data interpretation, and trend management skills.
- Knowledge of Part D Stars measures and their application in formulary strategy.
- Excellent communication and presentation skills, with the ability to engage leadership and cross-functional stakeholders.
- Strategic planning and execution within the Medicare environment.
- Ability to synthesize clinical, financial, and regulatory insights into actionable strategies.
- Strong analytical and problem-solving abilities.
- Proven project management skills, including timeline development, prioritization, and cross-functional coordination.
This is a remote-optional position, but ideally would be located in the Raleigh-Durham, NC area.
What You’ll Get
- The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
- Work-life balance, flexibility, and the autonomy to do great work
- Medical, dental, and vision coverage along with numerous health and wellness programs
- Parental leave and support plus adoption and surrogacy assistance
- Career development programs and tuition reimbursement for continued education
- 401k match including an annual company contribution
Salary Range
At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
$130,560.00 - $208,896.00
Skills
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