Job Description

Position Purpose: Define and develop standard and custom formularies for complex or specialized medications for assigned plan

• Develop clinical criteria for review of complex or specialized medications, recommend plan design changes and communicate recommendations to clients
• Monitor and review prior authorization/appeal requests for complex or specialized medications
• Develop and design clinical edits to adjudicate claims and enhance drug utilization
• Analyze pharmacy cost of care, trends, and coordinate the development of appropriate use protocols and guidelines
• Set criteria for medication analysis, coordinate reports to clients, meet regulatory reporting requirements for drug utilization review and fraud and abuse reporting
• Develop and implement medication therapy management programs.
• Evaluate program performance, recommend changes and ensure successful implementation of changes
• Ensure and evaluate quality controls and implement opportunities for performance improvement
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
• Provide clinical guidance and support to various departments and address clinical related questions
• Define, develop, implement and maintain standard and custom formularies and/or clinical edits and implement and maintain regulator required formularies and/or clinical edits, as required by your manager
• Provide formulary and/or clinical edit subject matter expertise, guidance and support to Formulary and Benefit Management team, various departments and plan pharmacy departments
• For Clinical Programs (Operational Excellence):
• Support ongoing evaluation of clinical program initiatives promoting quality, safety and cost of care opportunity
• Support oversight, development and expansion of clinical pharmacy programs and initiatives by assessing utilization trends and relevant data and literature
• Analyze pharmacy data and trends needed to drive positive member outcomes
• Ensure and develop strategic relationships supporting organizational strategic initiatives
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Bachelor’s degree or advanced degree (Pharm.D., M.S.) in pharmacy. 4+ years of mail order, retail, hospital, managed care pharmacy experience or pharmacy residency program experience.

Licenses/Certifications: Current state’s Pharmacist license with no restrictions

May be required to obtain additional state licensure based on business needs

For Clinical Programs (Operational Excellence): Support clinical program outcome analysis and evaluation across populations of patients in order to improve disease state outcomes and improve medication related safety. Support and assist in the development and analysis of various clinical programs to drive strategic initiatives across lines of business including Commercial, Medicaid, Medicare Part D and the Health Insurance Marketplace.

Pay Range: $107,700.00 - $199,300.00 per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act