Blue Cross NC · 18 hours ago
Manager - Medicare Formulary Strategy
United States
Full-time
Remote
Senior Level, Lead/Staff
$131K/yr - $209K/yr
8+ years expBlue Cross NC is a healthcare organization seeking a Medicare Formulary Strategy Manager to lead the design and execution of formulary strategies for Medicare products. The role involves collaboration with various teams to ensure formularies are effective, compliant, and competitive in the market.
Financial ServicesHealth InsuranceInsurance
Responsibilities
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
Qualification
Required
Bachelor's degree or advanced degree (where required)
8+ years of experience in related field
In lieu of degree, 10+ years of experience in related field
Current valid active unrestricted state(s) RPH license required
Preferred
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
Company
Blue Cross NC
It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Tunde Sotunde
President and Chief Executive Officer
Caleb Davies
Medicaid Market CFO - Healthy Blue of NC Medicaid
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