Pharmacy Benefits Strategist

About the position

The Pharmacy Benefits Strategist plays a crucial role in supporting the pharmacy benefit and reporting processes at PacificSource Health Plans. This position involves collaborating with various teams to design, implement, and coordinate pharmacy program initiatives, ensuring compliance with regulations and achieving 5-Star goals. The strategist will focus on Pharmacy Benefit Management (PBM) operations, data analytics, and process improvement to enhance the quality and efficiency of pharmacy services for members.

Responsibilities

• Provide oversight and quality assurance for pharmacy benefit designs and formulary coding.
• Collaborate with Sales, Product Development, and Pharmacy teams for optimal pharmacy benefit designs.
• Generate and analyze claims data and formulary comparisons for the Sales team.
• Manage vendor/client interfaces for efficient coding and PBM operations.
• Support formulary administrators on pharmacy benefit initiatives across all business lines.
• Perform ongoing drug and claim configuration setup and testing.
• Conduct claims research and analysis during audits.
• Generate reports for new and transitioning groups.
• Develop and maintain Pharmacy department policies and procedures.
• Organize and support departmental performance dashboards.
• Track and record drugs at launch for coverage decisions.
• Support communication efforts with members, pharmacies, and providers.
• Build reports and perform data extraction for pharmacy reporting and analysis.
• Analyze claims to identify cost savings and process improvements.
• Present data and findings to internal and external teams.
• Participate in special projects and committees.

Requirements

• Minimum of five years of experience in a healthcare field, preferably in managed care or pharmacy.
• Experience with Medicare Star ratings, Medicaid quality initiatives, and NCQA standards is preferred.
• Experience with Pharmacy benefit managers and project management is preferred.
• Bachelor's degree required, preferably in public health, healthcare, mathematics, statistics, data science, or a related field.
• Strong preference for certification in data software such as RxClaim, SQL, SAS, Excel, or Tableau.
• Strong computer skills and proficiency in Microsoft Word and Excel.
• Excellent verbal and business writing skills.
• Good understanding of Medical Terminology.
• Ability to manage workload without direct supervision and meet strict deadlines.
• In-depth knowledge of RxClaim PBM software is preferred.
• Ability to perform claims analysis and identify solutions.

Nice-to-haves

• Experience with SQL is preferred.
• Knowledge of coding and analytics is required.

Benefits

• Health insurance
• Dental insurance
• 401k retirement plan
• Paid holidays
• Flexible scheduling
• Professional development opportunities