Medicare and Duals Pharmacy Analyst
Spaulding Rehabilitation
Site: Mass General Brigham Health Plan Holding Company, Inc.
Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.
We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.
The Medicare Pharmacy Analyst will be responsible for supporting various aspects of Medicare and Dual-eligible plan formulary development, clinical program analysis and implementation of all Medicare and Dual pharmacy functions. The role will work closely with the whole Clinical Pharmacy Operations team to manage yearly, and day-to-day clinical and operational tasks required of the team related to the Medicare pharmacy benefit. This role will also work closely with other stakeholder departments to ensure all the Medicare and Dual-eligible pharmacy documents are updated and posted accurately on a monthly, yearly, and ad hoc basis. Overall, this role will include pharmacy related research, data analysis, documentation, and program oversight while ensuring compliance with all CMS and state regulations related to applicable Medicare and Dual-eligible product lines.
Principal Duties and Responsibilities:
• Assist in Development of Medicare and Dual-eligible Custom Formularies:
o Perform comprehensive analysis of pharmacy data (including but not limited to claims, competitor comparisons, trend analysis and market data) to develop formulary structure and drug coverage recommendations
o Develop custom formulary recommendations supporting Medicare Star ratings and other measures set forth by applicable governing bodies
o Prepare materials for presenting custom formulary coverage and changes to various committees
o Responsible for building and reviewing custom formulary submission files for accuracy and compliance with all CMS requirements
o Perform extensive analysis on custom formulary submission files to ensure accuracy and compliance with Centers for Medicare and Medicaid Services (CMS) requirements
o Develop and review various pharmacy-related, Medicare required member materials and web content ensuring accuracy and schedule of posting is followed
o Work collaboratively with Clinical Pharmacist and coordinate with other Medicare Pharmacy Analysts to finalize proposed custom Medicare formularies for presentations at various required committees for approval
• Maintain Medicare and Dual-eligible Custom Formularies:
o Manage and coordinate various aspects of Medicare custom formulary submissions, updates, reviews
o Track new product approvals and launches to ensure new drug reviews and coverage decisions are made within required CMS timelines
o Manage developing and updating formulary-related member documents
o Responsible for reviewing, developing, and updating Medicare CMS submissions, and related content according to CMS timelines and requirements
o Manage and take lead on Medicare Clinical Formulary source of truth documents while obtaining input and reviews done by the Clinical Pharmacist and other Medicare Pharmacy Analysts
• Review all CMS and applicable state updated regulations, requirements, and frequent memos to ensure continued compliance
o Responsible for coordinating with Clinical Pharmacy Operations team for any actions required involving pharmacy
o Track all memos and Clinical Pharmacy Operations team actions for future audits
• Ensure Readiness for Medicare and Dual-eligible Plan Audits
o Maintain high-quality, and utilize CMS best practices in documentation related to formulary audit documents
o Represent Medicare Clinical Pharmacy Operations team and MGBHP in all pharmacy-related audits as a Medicare and Duals formulary and Pharmacy subject matter expert (SME)
o May include support or speaking roles
o Key point person for pharmacy-related research and responses
o Record and maintain records before, during and after audit
• Participate in Pharmacy Trend Management:
o Perform data collection and analysis to develop recommendations of strategies to maximize high-quality, cost-effective strategies
o Develops and leads monitoring, tracking and reporting related to trend and pharmacy strategies
o Develop tracking grids related to drug launches, Medicare eligibility and formulary updates
o Oversee aspects of implementation of formulary and pharmacy-related strategies
• Lead various aspects of pharmacy and Pharmacy Benefit Manager (PBM) oversight and monitoring of pharmacy and formulary benefit to ensure Medicare compliance
• Lead clinical implementation, monthly maintenance, and oversight of formulary files for various broker exchanges on a monthly and yearly basis
• Develop and manage oversight of pharmacy-related vendors to ensure compliance with CMS Medicare requirements
• Develop internal and external facing educational materials, newsletters and talking points related to Medicare pharmacy content
• Attend and present pharmacy material at various committees as needed including but not limited to Pharmacy and Therapeutics (P&T), Drug Coverage Committee (DCC), etc.
• Manage various CMS Medicare and internal reports related to pharmacy
• Work independently and in collaboration the larger Medicare Clinical Pharmacy Operations team
• Address, escalate and track pharmacy related issues in coordination with the Medicare Clinical Pharmacy team and the PBM
• Coordinate work with other specialists and analysts on the team
• As an integral member of a larger clinical team, may be asked to provide support and/or collaborate with Clinical Pharmacist(s) and larger clinical team as a whole on other lines of business.
• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Other duties as assigned with or without accommodation.
At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.
At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.
Job Summary
Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.
We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.
The Medicare Pharmacy Analyst will be responsible for supporting various aspects of Medicare and Dual-eligible plan formulary development, clinical program analysis and implementation of all Medicare and Dual pharmacy functions. The role will work closely with the whole Clinical Pharmacy Operations team to manage yearly, and day-to-day clinical and operational tasks required of the team related to the Medicare pharmacy benefit. This role will also work closely with other stakeholder departments to ensure all the Medicare and Dual-eligible pharmacy documents are updated and posted accurately on a monthly, yearly, and ad hoc basis. Overall, this role will include pharmacy related research, data analysis, documentation, and program oversight while ensuring compliance with all CMS and state regulations related to applicable Medicare and Dual-eligible product lines.
Principal Duties and Responsibilities:
• Assist in Development of Medicare and Dual-eligible Custom Formularies:
o Perform comprehensive analysis of pharmacy data (including but not limited to claims, competitor comparisons, trend analysis and market data) to develop formulary structure and drug coverage recommendations
o Develop custom formulary recommendations supporting Medicare Star ratings and other measures set forth by applicable governing bodies
o Prepare materials for presenting custom formulary coverage and changes to various committees
o Responsible for building and reviewing custom formulary submission files for accuracy and compliance with all CMS requirements
o Perform extensive analysis on custom formulary submission files to ensure accuracy and compliance with Centers for Medicare and Medicaid Services (CMS) requirements
o Develop and review various pharmacy-related, Medicare required member materials and web content ensuring accuracy and schedule of posting is followed
o Work collaboratively with Clinical Pharmacist and coordinate with other Medicare Pharmacy Analysts to finalize proposed custom Medicare formularies for presentations at various required committees for approval
• Maintain Medicare and Dual-eligible Custom Formularies:
o Manage and coordinate various aspects of Medicare custom formulary submissions, updates, reviews
o Track new product approvals and launches to ensure new drug reviews and coverage decisions are made within required CMS timelines
o Manage developing and updating formulary-related member documents
o Responsible for reviewing, developing, and updating Medicare CMS submissions, and related content according to CMS timelines and requirements
o Manage and take lead on Medicare Clinical Formulary source of truth documents while obtaining input and reviews done by the Clinical Pharmacist and other Medicare Pharmacy Analysts
• Review all CMS and applicable state updated regulations, requirements, and frequent memos to ensure continued compliance
o Responsible for coordinating with Clinical Pharmacy Operations team for any actions required involving pharmacy
o Track all memos and Clinical Pharmacy Operations team actions for future audits
• Ensure Readiness for Medicare and Dual-eligible Plan Audits
o Maintain high-quality, and utilize CMS best practices in documentation related to formulary audit documents
o Represent Medicare Clinical Pharmacy Operations team and MGBHP in all pharmacy-related audits as a Medicare and Duals formulary and Pharmacy subject matter expert (SME)
o May include support or speaking roles
o Key point person for pharmacy-related research and responses
o Record and maintain records before, during and after audit
• Participate in Pharmacy Trend Management:
o Perform data collection and analysis to develop recommendations of strategies to maximize high-quality, cost-effective strategies
o Develops and leads monitoring, tracking and reporting related to trend and pharmacy strategies
o Develop tracking grids related to drug launches, Medicare eligibility and formulary updates
o Oversee aspects of implementation of formulary and pharmacy-related strategies
• Lead various aspects of pharmacy and Pharmacy Benefit Manager (PBM) oversight and monitoring of pharmacy and formulary benefit to ensure Medicare compliance
• Lead clinical implementation, monthly maintenance, and oversight of formulary files for various broker exchanges on a monthly and yearly basis
• Develop and manage oversight of pharmacy-related vendors to ensure compliance with CMS Medicare requirements
• Develop internal and external facing educational materials, newsletters and talking points related to Medicare pharmacy content
• Attend and present pharmacy material at various committees as needed including but not limited to Pharmacy and Therapeutics (P&T), Drug Coverage Committee (DCC), etc.
• Manage various CMS Medicare and internal reports related to pharmacy
• Work independently and in collaboration the larger Medicare Clinical Pharmacy Operations team
• Address, escalate and track pharmacy related issues in coordination with the Medicare Clinical Pharmacy team and the PBM
• Coordinate work with other specialists and analysts on the team
• As an integral member of a larger clinical team, may be asked to provide support and/or collaborate with Clinical Pharmacist(s) and larger clinical team as a whole on other lines of business.
• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Other duties as assigned with or without accommodation.
Qualifications
Qualifications
Bachelor’s degree in a related field required or the equivalent combination of training and experience, plus two years of Medicare and Dual-eligible pharmacy-related experience. At least three years of experience in managed care pharmacy.At least 1-2 years of Medicare pharmacy-related experience.Experience with benefit and drug coding logic for adjudication and formulary management.Experience with CMS and state regulatory audits.
Licenses and Credentials
Knowledge, Skills, and Abilities
Additional Job Details (if applicable)
Physical Requirements
Standing Occasionally (3-33%)Walking Occasionally (3-33%)Sitting Constantly (67-100%)Lifting Occasionally (3-33%) 20lbs - 35lbsCarrying Occasionally (3-33%) 20lbs - 35lbsPushing Rarely (Less than 2%)Pulling Rarely (Less than 2%)Climbing Rarely (Less than 2%)Balancing Occasionally (3-33%)Stooping Occasionally (3-33%)Kneeling Rarely (Less than 2%)Crouching Rarely (Less than 2%)Crawling Rarely (Less than 2%)Reaching Occasionally (3-33%)Gross Manipulation (Handling) Constantly (67-100%)Fine Manipulation (Fingering) Frequently (34-66%)Feeling Constantly (67-100%)Foot Use Rarely (Less than 2%)Vision - Far Constantly (67-100%)Vision - Near Constantly (67-100%)Talking Constantly (67-100%)Hearing Constantly (67-100%)
Remote Type
Remote
Work Location
399 Revolution Drive
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
EEO Statement:
Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
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