Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

The Director of Medicare Formulary and Clinical Services is responsible for oversight and maintenance of Medicare medication management strategies. This leader will take both prospective and retrospective views of targeted drug utilization to perform continuous quality and utilization improvement. Oversight of the future drug pipeline and planning, oversight of the formulary management process, oversight of pharmacy trends and reporting will all be key responsibilities of this position. This role will work cross-functionally within Capital in alignment with medical and corporate strategy. This leader will also ensure Pharmacy Benefit compliance with regulatory agencies including CMS, DOI, DOH, NCQA, among others.

• Oversee the formulary management process.
• Oversee Medicare drug benefit design and maintenance.
• Monitor the pipeline and work collaboratively to establish clinical management pathways.
• Work with actuarial services and stop loss teams to make impact projections of specific drug classes.
• Ensure alignment of formulary decision making with stakeholders in Government Programs.
• Ensure accuracy and timely maintenance of member formulary resources and communications.
• Work in collaboration with the Medical Policy team to manage pharmacy formulary across benefits.
• Monitor drug utilization and expense trends closely to initiate management strategies.
• Oversee collaborations with regional health systems to improve medication quality management.
• Collaborate with Member Services to ensure high levels of performance of the pharmacy benefit.

Skills:

• Leadership ability to effectively lead and manage professional and non-professional staff.
• Ability to interact effectively with internal and external leaders.
• Ability to think strategically and plan effectively.
• Effective communication skills both written and verbal.
• Effective presentation skills.
• Effective people management skills.
• Effective time and priority management skills.

Knowledge:

• Extensive clinical knowledge of medical and pharmacy practice management strategies required.
• Extensive practical application experience of formulary strategies required.
• Extensive knowledge of completing evidence-based formulary reviews, supportive literature evaluation, development of clinical pharmacy programs, presenting clinical information to providers and committees required.

Experience:

• 7 Years of prior experience in a managed care setting or PBM required.
• Minimum 3 years experience leading professional and non-professional staff required.

Education and Certifications:

• Doctorate of Pharmacy Degree from an accredited college of pharmacy required.
• Active and unrestricted pharmacy license in the State of Pennsylvania required.
• Pharmacy Practice residency preferred.
• Masters in Business Administration preferred.

Location: 

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays. 

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must occasionally lift and/or move up to 5 pounds.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.    
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.