Operations Specialist, Experienced

Your Role

The Formulary Management team leads the development and maintenance of multiple formularies to support competitive health plan products, manage cost-of-healthcare, and meet regulatory requirements for all lines of business including Commercial Large Group, Commercial Small Group, Individual/Family plan, and Medicare. The Operations Specialist, Experienced will report to the Senior Manager of Formulary Management. In this role you will be a subject matter expert that will lead efforts with formulary for pharmacy claim adjudicator and other vendors to ensure maintenance, validation, and audits are compliant with business needs. You will support in the development and maintenance of the formularies for all Blue Shield lines of business - Commercial, Exchange, and Medicare. This role is responsible for supporting day-to-day operations, maintaining of formulary and drug list databases, supporting P&T materials and documentation, maintaining desk-level procedures as well as job aids, and creating reports. The Operations Specialist, Experienced will collaborate with the pharmacy claim adjudicator, analytics, benefits and claims, Pharmacy Market Experience, Compliance, prior authorization, and customer services departments to communicate formulary and utilization management changes, formulary intent, and to ensure that formulary decisions are implemented in accordance with business rules and regulatory requirements.

Your Work

In this role, you will:

• Maintain formulary databases and associated utilization management edits related to weekly drug updates and required for business operations related to Formulary Management for Commercial, Exchange, and Medicare lines of business. Review systems and applications and recommend system edits/changes as needed

• Act as subject matter expert and review operational workflows, identifying problems and develop improvements, modifications, and enhancements; identify technical formulary issues that would prevent or delay CMS approval of BSC formularies; notify appropriate managers of Medicare formulary issue requiring immediate attention for resolution; determine appropriate workflow required for maintaining formulary decisions

• Develop and evaluates tools and materials that enhance operating efficiency and accuracy related to Formulary management, both internal to the team and across the department and in conjunction with external vendors used to manage and maintain the formulary for all lines of business. 

• Develop and transmit the documentation required to notify CMS of formulary, prior authorization criteria, and step therapy criteria changes.

• Develop required Commercial and Medicare printed formulary documents and work with the Pharmacy Communications, Medicare Marketing, and Web/Mobile teams to make these documents available in print and online. Assist with updating content and web posting requirements including drug coverage requirements such as prior authorization and step therapy criteria.

• Participate as a subject matter expert in the development of written guidelines and documents desk level procedures and policy and procedures 

• Maintain and adheres to regulatory requirements for Department of Managed Health Care (DMHC), Exchange, and Medicare as subject matter expert related to formulary submissions, notification to internal/external stakeholders of changes to utilization management edits, and generation/distribution of collateral, including letters, websites, and formulary PDFs.

• Validate claims to ensure formulary implementation is consistent with formulary decisions and regulatory requirements

• Coordinates operational implementation of formulary decisions as subject matter expert with internal teams (e.g, Drug Utilization Review, Pharmacy Benefit & Claims, Pharmacy Market Experience) and external teams (Pharmacy Benefits Adjudicator) 

• Act as subject matter expert of formulary operational workflows for implementing formulary decisions in compliance with state and federal regulations and audits

• Occasional business travel required
• Other duties as assigned.

Your Knowledge and Experience

• Requires a bachelor’s degree or at least 3 years of equivalent experience

• Requires at least 2 years of prior relevant experience within Pharmacy Services (e.g., claims, customer service, benefits, prior authorization, formulary)

• Experience working with Pharmacy Benefit Management systems or vendors

• Knowledge of Pharmacy Benefit design and Formulary configuration; knowledge of Blue Shield of California (or similar health care organization) pharmacy configuration is preferred

• Requires California Pharmacy Technician Certification

• Requires strong skills in standard Microsoft Office applications (e.g., Excel, Word, Outlook)

• Requires strong coordination and interpersonal skills working in a matrixed environment with multiple stakeholders

• Familiarity with Medispan drug files is preferred

• Broad knowledge of technical and operational practices of formulary decision documentation, regulatory submission, and implementation in the claims processing system is preferred

• Familiarity with Medispan drug files is preferred

• Knowledge of Medicare Part D and Commercial formularies is preferred

About Stellarus and the Ascendiun Family of Companies

Stellarus, launched in January 2025, is designed to scale innovative healthcare solutions that support customers in creating a health care experience deserving of their family, friends, and neighbors.    
 
Stellarus is part of a family of organizations that is overseen by a nonprofit corporate entity named Ascendiun. The Ascendiun Family of Companies also includes Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan and Altais, a clinical services company. 

Stellarus’ vision is to empower its customers to create a healthcare experience that is worthy of their family, friends, and neighbors. Stellarus’ objective is to offer innovative, modern, scalable solutions that challenge the health care status quo. This very closely aligns with Blue Shield of California’s vision by using innovation to improve quality, affordability, and experience for members.   

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Our Values: 

At Stellarus, our core values of agility, trust, drive, courage and service shape our approach to developing innovative product offerings.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail. 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.