Job Description Join our dynamic team as a Medicare Formulary Strategy Director! In this pivotal role, you will spearhead the design, development, and implementation of formulary strategies for all Medicare plans, including MAPD (HMO, PPO, DSNP), PDP, and EGWP. You will collaborateclosely with cross-functional teams such as Medicare Pharmacy Operations, Utilization Management Operations, Compliance, STARS, Medical Management, Actuary, Product, Clinical, and Finance to ensure that formularies are not only clinically appropriate but also cost-effective, competitive, and compliant with CMS regulations. How You Will Make an Impact: Formulary Development & Strategy Lead the annual Medicare formulary planning process from kick-off to CMS submission and final approval. Develop and execute innovative Medicare formulary strategies that harmonize clinical efficacy, cost-effectiveness, compliance, and competitive positioning. Conduct thorough competitive analyses and evaluate rebate opportunities while aligning product strategies with market needs. Support the creation of customized formularies that meet the distinct needs of various Medicare products. Research market trends and analyze competitive positioning to inform strategic decisions for Medicare formularies. Governance & Review Participate actively in the Pharmacy & Therapeutics (P&T) committee and Business Assessment Committee, ensuring decisions are evidence-based and compliant with CMS. Collaborate with Actuarial, Finance, Clinical, and Product teams to model financial scenarios and assess member impacts. Conduct ongoing and ad hoc assessments focusing on specialty tiers, utilization management, STARS performance, and high-cost/high-trend drugs. Ensure P&T compliance with CMS regulatory standards. Collaborate with PBM and internal partners to secure CMS approval for formularies. Market Monitoring & Trends Continuously monitor emerging drug trends and market dynamics to identify new opportunities or risks. Partner with Actuary and Data & Analytics teams to analyze formulary performance and track trends. Refine strategies based on insights derived from market intelligence and performance analyses. What You Bring: Bachelor's degree or advanced degree (if applicable). 8 years of experience in a related field; or 10 years of relevant experience in lieu of a degree. Valid unrestricted state(s) RPH license is required. Bonus Points (preferred qualifications): At least 5 years of Medicare managed care pharmacy experience or a combination of education and experience that provides an equivalent background. Advanced degree preferred (PharmD, MBA, MPH, or equivalent). A 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. Knowledge of Medicare regulatory requirements for Pharmacy and Therapeutics Committees. Excellent analytical, data interpretation, and trend management skills. Familiarity with Part D Stars measures and their application in formulary strategy. Exceptional communication and presentation skills for engaging stakeholders. Strategic planning and execution experience in the Medicare environment. Ability to synthesize insights into actionable strategies. Strong problem-solving skills and project management abilities. This is a remote-optional position, ideally situated in the Raleigh-Durham, NC area. What You'll Receive: An opportunity to work at the forefront of health care delivery with a team devoted to community wellbeing. Work-life balance, flexibility, and the autonomy to thrive. Comprehensive health coverage including medical, dental, and vision along with wellness programs. Parental leave and support alongside adoption and surrogacy assistance. Career development programs and tuition reimbursement for your continued education. A competitive 401k match, including an annual company contribution. Salary Range: At Blue Cross NC, we take pride in delivering fair and equitable compensation based on market standards. Our salaries are positioned near the middle of the range, considering experience, specialized skills, licensure, and organizational needs. The 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. *Incentive based on annual corporate goals and individual performance. $130,560.00 - $208,896.00 Important Note: Be aware of job scams. We do not ask for financial information during the recruitment process. All our job opportunities are listed on our official career page. If you suspect fraudulent activity, please report it to your local authorities and to our HR department.
