Manager – Medicare Formulary Strategy
E-Verify Program
full-time
Posted on:
Location Type: Remote
Location: North Carolina • United States
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Salary
💰 $130,560 - $208,896 per year
About the role
- 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.
- Collaborate 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.
- 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.
- 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.
- 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.
Requirements
- Bachelor's degree or advanced degree (where required)
- 8+ years of experience in related field.
- Current valid active unrestricted state(s) RPH license required.
- 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.
Benefits
- 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
- Work-life balance, flexibility, and the autonomy to do great work
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
formulary managementMedicare Part DMedicare Part Bdata interpretationtrend managementcompetitive analysisfinancial modelingutilization managementclinical efficacy assessmentregulatory compliance
Soft Skills
analytical skillsproblem-solving abilitiescommunication skillspresentation skillsstrategic planningcross-functional collaborationproject managementsynthesis of insightsleadership engagementprioritization
Certifications
RPH licensePharmDMBAMPH