Director Health Plan Pharmacy Benefit Operations Management

Profile

Description

The Director, Formulary Operations Management provides clinical and operational leadership for build, maintenance, submission, and updating of formularies and drug lists. The Director, Formulary Operations Management requires an in-depth understanding of how organization capabilities interrelate across the function or segment.

Responsibilities

The Director, Formulary Operations Management ensures accuracy of formularies and utilization management (UM) criteria in the Centralized Formulary System. Collaborates with healthcare professionals, pharmacists, and other business functions to operationalize formularies. Performs formulary analysis and reporting to ensure optimal operational flow. Develops key performance indicators and plans to improve overall process improvements and efficiency. Creates formulary management process and training documentation. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy.

Review PBM clinical decisions in accordance with medical necessity and contract criteria and challenge appropriateness.

Review pharmacy claims data for proactive outreach and intervention

Identify and monitor inappropriate trends in care to improve PBM effectiveness in ensuring quality and cost effectiveness with a focus on:

Eliminating utilization of 'me too' drugs

Shifting generic utilization from high cost to low-cost generics, (eg. maximizing generic efficiency rate).

Auditing step therapy programs to ensure that high-cost drugs are covered only when less costly alternatives have been evaluated and

Monitoring efforts to fill scripts through mail order distribution channel when appropriate.

Implement programs to ensure that mail order programs do not drive excess or waste ingredient scripts.

Identifying and eliminating spend on prescription drugs where OTC alternatives are available.

Develop and maintain a 'vigilant drug' list of high cost / low quality drugs. Monitor utilization, and work with the PBM to reduce or eliminate spend on low value drugs.

Evaluate distribution channels for specific ingredients including:

High-cost specialty drugs and ensure that medical plan and pharmacy benefit design steer member care to the lowest cost distribution channel.

Evaluating and transitioning specialty drugs that may be acquired through manufacture direct programs when appropriate.

Monitor acquisition costs for generic drugs.

Assist the Benefits team in:

Monitoring current Rx spend within the health plan.

Reporting progress of current initiatives to control current spend.

Forecasting and budgeting future Rx spend.

Reconciling current Rx spend to forecast and budget

Monitoring invoicing and rebates to ensure compliance with PBM contract.

Evaluating the impact of COVID on historical and current script utilization.

Coordinate benefit plan design elements (eg coinsurance and deductibles) with pharmacy initiatives to maximize spend steerage.

Required Qualifications

PharmD

8 or more years of technical experience

5 or more years of management experience

Ability to manage multiple tasks and deadlines with attention to detail.

Ability to communicate effectively and deliver presentations to Humana leadership

Able to give direction and make sound business decisions.

Leadership experience as a supervisor, manager or director

Experience with driving engagement and promoting a positive business culture

Proficiency in Microsoft Word, Excel, PowerPoint & Outlook

Strong problem solving, critical thinking and analytical skills

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

Process Improvement skills

Project Management skills

Lean/Six Sigma (or other quality/process program) experience

Additional Information

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters.

Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Company info

Humana Inc.
Website : http://www.humana.com