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.”

This position is responsible for the development, maintenance, and evaluation of pharmacy clinical initiatives and utilization management programs to assure a consistently cost-effective and quality pharmaceutical services and benefits for plan members. The incumbent manages the drug formulary program as well as clinical activities and oversees the clinical program administration by the pharmacy benefit management (PBM) company. The incumbent also serves as a resource to providing clinical support to committees and workgroups such as Pharmacy and Therapeutics Committee, Medical Policy Committee, Quality Management Committee, Delegation Oversight, and HEDIS/NCQA. The incumbent possesses good clinical/analytical skills and sound decision-making capabilities to identify opportunities/risks and propose benefit program quality/utilization management strategies accordingly. Strong interpersonal and excellent communication skills are essential due to interaction with various members of the medical profession, managed care clients, and external organizations.

• Formulary management including drug evaluation, P&T Committee, and related physician and member collaterals
• Pharmaceutical utilization and trend management via pharmacy clinical initiatives
• PBM vendor clinical services and programs oversight
• Specialty pharmaceutical management
• Pharmacy clinical and utilization management criteria, protocol, policies, and procedure development
• Provide clinical and drug information support
• Maintain regulatory including state insurance department, CHIP, and NCQA accreditation compliance
• Develop member, broker, and provider educational programs
• Conduct presentation and training
• Maintain provider and pharmaceutical industry/drug manufacturer relations.
• Staff supervision

Skills:

• Strong interpersonal and team skills with ability to work and interact externally and internally. Ability to communicate effectively with varied audiences, including ability to lead meetings, develop teamwork, and deliver verbal presentations. Ability to take direction from various levels of staff and perform project work with minimal supervision.
• Strong clinical/analytical skills and decision-making capabilities required. Strong interpersonal and excellent communication skills required. Ability to assess utilization data to identity new opportunities.

Knowledge:

• Managed care knowledge and experience highly preferred. In-depth knowledge of drug formulary systems and drug evaluation process. Broad knowledge of outpatient drug benefit and utilization management programs. Knowledge of pharmacy claims processing along with applicable state/federal laws. Knowledge and experience with Medicare Part D and NCQA accreditation preferred. Knowledge and experience with therapy medication and disease state management. Possess working knowledge of medical and pharmacy data integration to close gap in care and facilitate greater care coordination.

Experience:

• Experience in developing pharmacy clinical protocol, policies, and procedures. Experience in design/deployment of programs to increase quality of care and decrease costs.

Education and Certifications:

• Pharmacy degree and current Pennsylvania pharmacy license required. Advanced pharmacy degree (Masters or Pharm.D.) preferred.

Work Environment:

• Working environment includes typical office conditions.

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 be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds. Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.

Other:

• Performs other related duties and assignments as directed.
• Travel less than 1%. Occasional overnight travel and travel between CBC locations.

 

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 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.