Senior Manager, Clinical Medicare & Formulary Operations

Summary

Join Rightway as a Senior Manager, Clinical Medicare & Formulary Operations to lead the development and optimization of Medicare-focused formulary strategies. You will ensure Medicare Part D compliance, manage formulary workflows, and contribute to strategic rebate planning. This role requires deep Medicare expertise, including MTM programs and formulary compliance, along with strong clinical and analytical skills. You will collaborate cross-functionally with Clinical, Product, Data & Insights, and Marketing teams. The position involves leading formulary design, deployment, and maintenance, ensuring regulatory standards and audit readiness. You will also partner with rebate aggregators and pharmaceutical manufacturers, applying clinical data to inform formulary decisions.

Requirements

• PharmD required
• 5+ years of pharmacy experience working for a health plan or PBM with 3+ years of Medicare experience
• Strong expertise in formulary operations and regulatory requirements
• Deep understanding of formulary development, CMS compliance, MTM programs, and Medicare audit processes
• Experience working with rebate aggregators or manufacturers in formulary and rebate strategy
• Highly analytical, with the ability to use data and clinical insights to guide formulary strategy and decision-making
• Familiar with formulary coding in PBM platforms and claims testing processes
• Strong collaborator and communicator, with the ability to work cross-functionally and influence stakeholders
• Comfortable operating in a fast-paced, evolving environment with a proactive, ownership-oriented mindset

Responsibilities

• Lead the design, deployment, and maintenance of Rightway’s formularies, including custom and standard drug lists
• Oversee Medicare formulary operations, ensuring alignment with regulatory standards and audit readiness, including support for Medication Therapy Management (MTM) and CMS compliance
• Monitor and analyze regulatory and legislative requirements, develop project plans to meet requirements, and lead cross functional teams to implement programs to meet requirements
• Serve as a clinical and strategic partner in rebate-related activities—collaborating with rebate aggregators, pharmaceutical manufacturers, and health plans—and provide clinical input into financial modeling and evaluations
• Apply clinical effectiveness data and analytical tools to inform formulary decisions and strategies
• Collaborate with the claims platform team to ensure accurate formulary coding and functionality; support regular formulary testing and validation
• Contribute to and support Rightway’s P&T Committee with strategic insights, drug evaluations, and formulary performance updates
• Partner with Product, D&I, and Marketing to evolve our formulary solutions and bring them to market in ways that enhance the member experience
• Facilitate communication to and education of clients, members, and internal staff regarding clinical issues and objectives
• Provide support to operational teams and clients during implementation
• Explore and support the implementation of non-traditional formulary designs that move beyond tier-based structures
• Support RFI and RFP submissions, as required
• Mentor or oversee team members as appropriate; people leadership experience is preferred

Preferred Qualifications

Experience with people leadership or mentoring preferred

Benefits

$130,000-$140,000/yr