Job Description
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:
o Completing the clinical data analysis to design an optimal formulary and utilization management
o Collaborating with the Benefit Relationship Manager and Formulary Administration to clarify client clinical requirements to design and develop formulary and utilization management edits
o Reviewing and obtaining approval from client on the design of formulary and utilization management
o Consulting and influencing the client on standard and custom formulary options and utilization management edits
o Reviewing identified defects during testing and helping to resolve these defects, including consulting with the client to re-define and clarify the clinical requirements
o Collaborating with internal partners to develop automation strategies and perform user acceptance testing as required
o Ensuring timely delivery of formulary and utilization management edits, including reviewing the test results with the client
o Meeting and/or exceeding CVSH yearly goals, including meeting and/or exceeding client service levels for turnaround times and accuracy
o 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. This position can be located in a Corporate Hub or has the ability to work remotely/work from home within the U.S. Clinical Operations Advisor must have the ability to travel up to 30% of the time.
Required Qualifications
Registered Nurse
1+ years pharmacist experience in a PBM or Managed Care setting
1+ year using MS Word, Excel, and Outlook, with experience creating and updating Excel spreadsheets
Understanding of UM and Formulary
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
Bachelor's Degree
Business Overview
At CVS Health, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, sex/gender, sexual orientation, gender identity or expression, age, disability or protected veteran status or on any other basis or characteristic prohibited 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.