Description
Pharmacy Benefits Administrator ConsultantKAI Partners, Inc. (KAIP) seeks a Pharmacy Benefits Administrator Consultant. They are primarily responsible for managing prescription drug benefits for health insurance plans by negotiating drug prices with manufacturers, developing formularies, processing prescription claims, and ensuring patients access the most cost-effective medications within their coverage plan; essentially acting as a middleman between pharmacies, drug manufacturers, and health insurers to control prescription drug costs while maintaining patient access to necessary medications.
Responsibilities - Providing consultation regarding policy formulation and oversight for all aspects of Medi-Cal's pharmacy, medical supply, and enteral nutrition benefits (Medi-Cal Rx), including state supplemental drug rebate negotiations and the federal drug rebate program.
- Assisting with Medicaid drug program policies and procedures, providing expert policy guidance and consultation on all Medicaid pharmaceutical matters.
- Developing, interpreting, evaluating, and implementing highly complex and sensitive pharmacy policy and legislative regulatory language.
- Creating and maintaining a list of covered drugs (formulary) with different tiers based on cost and therapeutic value, influencing which medications patients can access and at what price.
- Negotiating discounts and rebates with drug manufacturers to secure the best prices for health plans.
- Establishing a network of pharmacies where patients can access prescriptions at negotiated rates.
- Reviewing and processing prescription drug claims submitted by pharmacies, determining patient copays, and reimbursing pharmacies.
- Implementing prior authorization, step therapy, and quantity limits to ensure appropriate medication usage and cost control.
- Monitoring prescription drug trends and utilization patterns to identify areas for cost optimization.
- Managing formularies and promoting appropriate medication usage to ensure patients have access to necessary medications while controlling costs.
- Performing other related duties, as assigned.
Skills and Qualifications- Ability to negotiate with drug manufacturers, healthcare plan providers, and retail pharmacies to establish fair pricing strategies.
- Proficiency in collecting, assessing, and analyzing data to conclude, solve problems, and recommend pricing options.
- Strong ability to evaluate diverse factors such as economic trends, business strategies, and public health needs to ensure accurate and fair pricing.
- Excellent verbal and written communication to collaborate effectively with corporate leaders, retail managers, and insurance providers, ensuring alignment and workable solutions.
Work/Education Experience - PharmD or Bachelor's degree in healthcare, pharmacy, information systems, or a related field. (Mandatory)
- 3+ years of experience as a pharmacy benefits manager or administrator, including experience with formulary management. (Mandatory)
- Experience with pharmacy benefit management software and systems. (Preferred)
- Knowledge of state and federal regulations related to pharmacy benefits. (Preferred)
- Certification in pharmacy or healthcare-related fields (e.g., CPhT, CPC). (Preferred)
Compensation Range: $144,000 - $205,000The salary range for this role may vary depending on the specific geographic location where this position is ultimately filled. Several factors, including but not limited to a candidate's experience, education, skills, and certifications, pay equity, and organizational needs, are considered when determining the posted salary range. In addition, eligible roles also qualify for a comprehensive benefits package. Must be able to provide proof of education for all mandatory qualifications; all references will be verified. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.
KAI PartnersKAI Partners, Inc. is a Northern California-based small business that offers world-class management consulting and technology services to public and private sector clients on a variety of large-scale projects. The KAI Partners team has over 100 years of combined executive-level experience in information system design, development, implementation, and testing. Our clients benefit from our proven program management, project management, and oversight, program portfolio management, Agile services, organizational change management, training, enterprise architecture, managed IT service, and IT security support.