Formulary Operations Pharmacist

About Judi Health

Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels.

At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health .

Location: Hybrid (Local to New York, New York; Denver, Colorado; or Charlotte, North Carolina area)

Position Summary:

The Formulary Operations Pharmacist – Medicare is responsible for providing operational support for the evaluation, implementation, and maintenance of Medicare Part D formularies and utilization management. This individual supports creation and maintenance of formulary and utilization management lists, preparation of CMS formulary files and member formulary drug lists, preparation and review of updates for implementation, and other formulary and utilization management related tasks and processes. The role requires strong cross functional collaboration and communication skills, and an understanding of Medicare Part D formulary management processes and related CMS rules and regulations. The position also provide s support to non-Medicare formulary management tasks as opportunities arise.

Position Responsibilities:

Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelines

Supports the development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug lists

Leads and supports the preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, and utilization management criteria

Expanded scope of responsibilities across other non-Medicare business lines when needed, driving alignment, operational excellence, and strategic execution across diverse functions

Evaluate drugs and drug classes, to provide formulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalize

Evaluates the appropriateness of and operationalizes custom client formulary and benefit change requests within the formulary and adjudication platform

Creates customized marketing materials, including but not limited to member formulary drug lists, utilization management criteria documentation, and web-based look up tools

Supports the comprehensive testing of client formulary and benefit elections

Supports custom formulary client trade and rebate strategy evaluation

Identifies opportunities for automation and collaborates with Analytics to streamline processes and workflows

Analyzes pharmacy cost of care and clinical updates for the development of formulary management programs and utilization management edits

Provides clinical support to operational teams and clients during implementations

Serves as the clinical operations liaison to assist with ad-hoc sales requests and strategic communications for clients to provide expert insights from a clinical perspective

Quality assurance checks of Formulary Specialist activities, with emphasis on actions impacting adjudication of claims for accuracy

Provides cross functional support for claims troubleshooting within the adjudication platform

Monitors and analyzes regulatory and legislative requirements for Medicare

Leads and supports timely submission of all required reporting to State and Federal regulators, such as required formulary submissions to Health Plan Management System (HPMS)

Supports the development of project plans to meet new CMS requirements, and supports cross functional teams with implementation of programs to meet requirements

Leads formulary change processes within URAC/NCQA/CMS guidelines

Supports Pharmacy and Therapeutics (P&T) committee items, as required

Maintains and updates the Rx pharmaceutical pipeline, development of monthly newsletters, and other client communications as needed

Develops clinical criteria for review as needed

Supports CMS Program Audits as a formulary administration subject matter expert and provide necessary input of information to complete any auditor requested deliverables, including but not limited to root cause analysis, beneficiary impact analysis, and corrective action plans

Supports Quality Improvement projects, clinical value projects, and continuous improvement initiatives, as needed

Supports Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed

Support general business needs and operations, as needed

Supports review of new regulatory guidance and regulations that impact formulary administration and provide guidance to internal and external stakeholders for compliant action

Maintains compliance with all regulatory and organizational deadlines

Responsible for adherence to the Judi Rx Code of Conduct including reporting of noncompliance

Performs other duties and responsibilities as needed

Minimum Qualifications:

Doctor of Pharmacy (PharmD) Degree from an accredited institution

Current, unrestricted registered pharmacist license(s)

Residency/fellowship preferred

2+ years of Medicare formulary experience working for a health plan or PBM

Knowledge of formulary development and maintenance processes

Knowledge of highly managed specialty medications/strategy

Knowledge of rebate and financial implications of formulary strategies

Experience working with large datasets required

Ability to independently identify, research, and resolve issues

Ability to balance multiple complex projects simultaneously

Ability to work extended hours, weekends, and holidays consistent with industry demands

Exceptional written and verbal communication skills

Extremely flexible, highly organized, and able to shift priorities easily

Attention to detail & commitment to delivering high quality work product

Proficient in Microsoft office suite with stong emphasis in Microsoft Excel required

#LI-LC1

This range represents the low and high end of the anticipated base salary range. The actual base salary will depend on several factors such as: experience, knowledge, skills, and location of the job.

Remote, US Salary Range

$125,000 — $140,000 USD

New York, NY Salary Range

$125,000 — $140,000 USD

Denver, CO Salary Range

$125,000 — $140,000 USD

Charlotte, NC Salary Range

$125,000 — $140,000 USD

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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