Pharmacy Policy Manager

Summary

Join Oscar's Clinical Policy team as a Manager and help develop and review health insurance policies. You'll be responsible for the growing pharmacy policy program, ensuring high-quality, cost-effective decision-making, and contributing to high-quality member care. This role involves leading a team, managing policy development, and collaborating with various stakeholders. The position offers a blended work culture with remote options and a competitive salary and benefits package. You will report to the Senior Manager, Clinical Policy Development. The role requires significant experience in pharmacy and medical policy development and a PharmD degree.

Requirements

• PharmD degree
• Active, unrestricted pharmacist license
• 4+ years of experience with UM reviews
• 4+ years of experience with clinical research, policy development, and/or medical writing
• 3+ years of experience in Excel

Responsibilities

• Be accountable for the end-to-end process for development and review of pharmacy and medical drug guidelines and lead a team of contracted and/or matrixed reports to ensure timely review and submission of guideline updates in close partnership with our Pharmacy Operations team
• Take the lead in drafting, obtaining approval, and maintaining pharmaceutical and medical drug policies based on current clinical evidence and nationally-recognized standards
• Manage direct, contracted, and matrixed team members
• Responsible for ensuring processes and policies are streamlined and adhere to larger departmental strategy
• Prepare and present all materials for executive external view and feedback. Summarize changes and track evolution of pharmacy policy changes to support audit functions. Effectively communicates and presents results and recommendations across disciplines
• Responsible for high-complexity reviews that require extensive up to date industry expertise or contextual knowledge
• Partner with vendors to ensure accuracy of pharmacy code edits in claims system and prior authorization tooling and take an active role in policy customizations
• Maintain high levels of subject matter expertise on pharmaceutical pipeline trends, approvals, and changes in evidentiary standards. Track evidence submissions and feedback on policies, and prioritize policy updates
• Develop an in-depth understanding of regulatory and quality requirements applicable to our programs
• Ensure processes and documentation are in place and in compliance with State, Federal and NCQA requirements
• Provide support on regulatory audits and quality accreditation surveys, as needed
• Support our clinical leaders in disseminating feedback and conducting remediation
• Provide support on monitoring quality trends and identifying gaps to drive quality improvement activities
• Compliance with all applicable laws and regulations
• Other duties as assigned

Preferred Qualifications

• Experience working with the CVS portal and criteria, or with MCG
• Experience working in a fast-paced, collaborative environment
• Residency training completed from an accredited ASHP or AMCP program

Benefits

• Employee benefits
• Participation in Oscar's unlimited vacation program
• Annual performance bonuses
• Medical, dental, and vision benefits
• 11 paid holidays
• Paid sick time
• Paid parental leave
• 401(k) plan participation
• Life and disability insurance
• Paid wellness time and reimbursements
• Remote work option (with conditions)