Your Role

The Formulary Management team leads the development and maintenance of multiple formularies to support competitive health plan products, manage healthcare costs, and meet regulatory requirements across all lines of business including Commercial Large Group, Commercial Small Group, Individual/Family plans, and Medicare. The Business Analyst, Senior position reports to the Senior Manager of Formulary Management. In this role, you will determine requirements for the build, implementation, and maintenance of formularies, including utilization management strategies. You will also lead in creating custom solutions to ensure compliance with state and federal mandates by interpreting mandates, gathering requirements from business owners, developing implementation plans, documenting system processes, and coordinating with cross-functional business partners. You will act as a subject matter expert to ensure formulary decisions and drug lists align with business rules and regulatory standards, and you may support audits or lead projects with minimal supervision.

Your Knowledge and Experience

• Requires a college degree or equivalent experience


• Requires 5 years of relevant experience


• Experience working with Pharmacy Benefit Management systems or vendors


• Knowledge of Pharmacy Benefit design and Formulary configuration; familiarity with Blue Shield of California or similar health care organizations' pharmacy systems is preferred


• Understanding of regulatory requirements (Commercial and/or Medicare) related to formularies and utilization management


• Strong coordination and interpersonal skills for working in a matrixed environment with multiple stakeholders


• Familiarity with Medispan drug files is preferred


• Knowledge of project management principles


• Experience in documenting processes, identifying gaps, managing multiple projects, and applying industry best practices


• Knowledge of Commercial and Medicare Part D formulary requirements is preferred


• Understanding of California's pharmacy benefit compliance standards is preferred

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