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SalaryJob Description
This is a fully remote, work from home role open to candidates anywhere within the United States.
The Clinical Operations Advisor is a client facing role accountable for the design of the client formulary and utilization management programs in partnership the Health Plan (HP) Clinical Advisor, Benefit Relationship Manager, and Formulary Administration. The Clinical Operations Advisor collaborates with HP Clinical Advisor to understand the client’s clinical strategy and roadmap to create a clinical operations plan. The Clinical Operations Advisor works with the Benefit Relationship Manager and client to facilitate gathering formulary and utilization management requirements and designs the drug level set up for projects on the operations plan while ensuring compliance to internal best practice and federal and state guidelines.
This includes:
• Completing the clinical data analysis to design an optimal formulary and utilization management
• Collaborating with the Benefit Relationship Manager and Formulary Administration to clarify client clinical requirements to design and develop formulary and utilization management edits
• Reviewing and obtaining approval from client on the design of formulary and utilization management
• Consulting and influencing the client on standard and custom formulary options and utilization management edits
• Reviewing identified defects during testing and helping to resolve these defects, including consulting with the client to re-define and clarify the clinical requirements
• Collaborating with internal partners to develop automation strategies and perform user acceptance testing as require do Ensuring timely delivery of formulary and utilization management edits, including reviewing the test results with the client
• Meeting and/or exceeding CVSH yearly goals, including meeting and/or exceeding client service levels for turnaround times and accuracy
• Consulting with clients and developing a trusted consultative partnership that drives up client satisfaction The Clinical Operations Advisor designs the clinical set ups using Caremark technology solutions and supports the coding teams in the loading of clinical data into the adjudication system (RxClaim).
The Clinical Operations Advisor partners with clinical team members to document clinical design best practices, provide inputs to streamline processes, and identify opportunities to improve the efficiency and accuracy of clinical set ups. The Clinical Operational Advisor supports internal and client audits of clinical set ups within adjudication systems, which includes verifying the client approved requirements and design. The Clinical Operations Advisor should be able to manage multiple HP clients across multiple lines of business including Medicare, Medicaid, Exchange, and Commercial.
Pay Range
The typical pay range for this role is:
Minimum: 97,500
Maximum: 210,000
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
Active pharmacist license that is in good standing
1+ years pharmacist experience in a PBM or Managed Care setting
1+ year of UM and Formulary experience in PBM setting
1+ year using MS Word, Excel, and Outlook, with experience creating and updating Excel spreadsheets
Preferred Qualifications
• Experience supporting Pharmacy Benefit Management
(PBM) clients or within a health plan
• Experience in all market segments (Medicare, Medicaid,
Exchange and Commercial)
• Expertise in Utilization Management, Formulary
Management and Clinical Products
• Experience implementing template and/or customized
clinical programs
• Knowledge of PBM adjudication engine and other
systems leveraged in support of clients
• Proven leadership skills
• Experience with client service and relationship building
Education
PharmD or equivalent
Business Overview
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
This is a fully remote, work from home role open to candidates anywhere within the United States.
The Clinical Operations Advisor is a client facing role accountable for the design of the client formulary and utilization management programs in partnership the Health Plan (HP) Clinical Advisor, Benefit Relationship Manager, and Formulary Administration. The Clinical Operations Advisor collaborates with HP Clinical Advisor to understand the client’s clinical strategy and roadmap to create a clinical operations plan. The Clinical Operations Advisor works with the Benefit Relationship Manager and client to facilitate gathering formulary and utilization management requirements and designs the drug level set up for projects on the operations plan while ensuring compliance to internal best practice and federal and state guidelines.
This includes:
• Completing the clinical data analysis to design an optimal formulary and utilization management
• Collaborating with the Benefit Relationship Manager and Formulary Administration to clarify client clinical requirements to design and develop formulary and utilization management edits
• Reviewing and obtaining approval from client on the design of formulary and utilization management
• Consulting and influencing the client on standard and custom formulary options and utilization management edits
• Reviewing identified defects during testing and helping to resolve these defects, including consulting with the client to re-define and clarify the clinical requirements
• Collaborating with internal partners to develop automation strategies and perform user acceptance testing as require do Ensuring timely delivery of formulary and utilization management edits, including reviewing the test results with the client
• Meeting and/or exceeding CVSH yearly goals, including meeting and/or exceeding client service levels for turnaround times and accuracy
• Consulting with clients and developing a trusted consultative partnership that drives up client satisfaction The Clinical Operations Advisor designs the clinical set ups using Caremark technology solutions and supports the coding teams in the loading of clinical data into the adjudication system (RxClaim).
The Clinical Operations Advisor partners with clinical team members to document clinical design best practices, provide inputs to streamline processes, and identify opportunities to improve the efficiency and accuracy of clinical set ups. The Clinical Operational Advisor supports internal and client audits of clinical set ups within adjudication systems, which includes verifying the client approved requirements and design. The Clinical Operations Advisor should be able to manage multiple HP clients across multiple lines of business including Medicare, Medicaid, Exchange, and Commercial.
Pay Range
The typical pay range for this role is:
Minimum: 97,500
Maximum: 210,000
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
Active pharmacist license that is in good standing
1+ years pharmacist experience in a PBM or Managed Care setting
1+ year of UM and Formulary experience in PBM setting
1+ year using MS Word, Excel, and Outlook, with experience creating and updating Excel spreadsheets
Preferred Qualifications
• Experience supporting Pharmacy Benefit Management
(PBM) clients or within a health plan
• Experience in all market segments (Medicare, Medicaid,
Exchange and Commercial)
• Expertise in Utilization Management, Formulary
Management and Clinical Products
• Experience implementing template and/or customized
clinical programs
• Knowledge of PBM adjudication engine and other
systems leveraged in support of clients
• Proven leadership skills
• Experience with client service and relationship building
Education
PharmD or equivalent
Business Overview
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
