Job Title: Clinical Formulary Specialist

Location: Remote, CST or EST required

Job Summary:

The Clinical Formulary Specialist is responsible for managing the review, update, and compliance of medical policies and formularies. This role ensures accurate and up-to-date formulary criteria, supports rebate compliance, participates in committee reviews, and collaborates with internal and external stakeholders to maintain regulatory adherence and optimize formulary management.

Key Responsibilities:

• Conduct an annual review of approximately 300 medical policies, ensuring updates for new indications, J codes, NDCs, age restrictions, and alignment with current clinical guidelines.
• Collaborate with vendors to ensure all policies remain compliant with rebate requirements.
• Serve as a key member of the Restricted Recipient Committee, providing medication reviews, recommendations, and presentations.
• Complete approximately 350 medication reviews for New, New Trigger, and OMIG Restricted members, presenting findings and recommendations to the committee.
• Develop monographs, presentations, and policy updates for the Pharmacy and Therapeutics (P&T) Committee; provide formulary recommendations on a quarterly and ad hoc basis.
• Review and update branching logic configurations to ensure accuracy and correct claim adjudication.
• Ensure member and provider-facing documents are current and compliant with posting requirements.
• Oversee the completion of formulary disruption notifications, ensuring timely and accurate member communication.
• Conduct quality assurance (QA) reviews of guidebooks to ensure accuracy ahead of open enrollment.
• Participate in weekly "New Drug Call" meetings to determine formulary placement for new drugs and manage protected drug classes within the required 90-day period.
• Ensure Medicaid compliance by maintaining up-to-date criteria aligned with state regulations, providing quarterly MMCOR information, and updating the Preferred Drug List (PAD) as needed.
• Maintain and update Prior Authorization (PA) and Specialty Drug Lists per state regulatory requirements.
• Work closely with compliance teams to meet National Committee for Quality Assurance (NCQA) documentation requirements.
• Manage the completion of annual state submissions and regulatory surveys.
• Review high-dollar drug reports to ensure cost-effectiveness and policy alignment.

Key Skills & Competencies:

• Strong knowledge of formulary management, medical policy development, and regulatory compliance.
• Experience with Medicaid, Medicare, and other government healthcare programs.
• Expertise in pharmacy benefits, claim adjudication, and rebate compliance.
• Strong analytical and problem-solving skills with attention to detail.
• Excellent communication and presentation skills for committee participation and stakeholder collaboration.
• Ability to manage multiple projects in a fast-paced environment.
• Proficiency in pharmacy benefit management (PBM) reporting platforms and other healthcare technology systems.

Qualifications:

• PharmD required.
• Minimum of 5 years of experience in formulary management, regulatory compliance, or related healthcare operations.
• Experience working with PBM vendors, regulatory agencies, and internal compliance teams.
• Knowledge of state and federal healthcare regulations, including Medicaid and Medicare Part D requirements.
• Strong proficiency in Microsoft Office Suite and data analysis tools.

The pay for this role is $65 - $75 an hour DOE.

Benefits through CGC: Payday Fridays, Dental, Vision, STD and/or LTD, Voluntary Life & AD&D, Accident, Critical Illness, Hospital Indemnity, Health Advocate EAP, and Health Equity Commuter Benefits, ZayZoon, and 401k.

We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws