Council Of Health Insurance
Job title
Care Management Consultant
Job purpose
The jobholder is responsible for performing medical providers’ activities with minimal supervision including monitoring, inspection, and enablement of medical providers to ensure compliance with guidelines and standards.
Responsibilities
Oversee and drive insurance drug formulary strategy for CCHI to ensure its proper implementation and promotion among stakeholders
Develop and implement insurance formulary drug strategies including but not limited to prescribing edits, guideline adherence and generic switching.
Develop and update insurance drug formulary KPIs per stakeholder.
Evaluate and maintain formulary set-up based on clinical requirements, compliance with regulatory bodies, and PTC approvals.
Provides clinical and operational leadership for build, maintenance, submissions and updates of formularies and drug lists.
Communicate and receive formulary addition and update requests and dossiers from pharmaceutical manufacturer.
Ensures accuracy of formularies and utilization management criteria for the insurance drug formulary.
Resolves stakeholder’s benefits inquires in relation to insurance drug formulary.
Understanding of utilization management criteria for prescribing edits including but not limited to step therapy, prior authorization, and quantity limits.
Partners with CCHI insurance stakeholders to collect insights on insurance drug formulary expectations, barriers, challenges and feedback.
Actively participants in PTC and other committees including TAC and VAC.
Manages and communicates line of business priorities.
Becomes an expert in CCHI formulary management system and prescription drug data.
Performs formulary analysis and reporting.
Develops and leads metrics discussions to deliver process improvements and business results.
Leads insurance drug formulary related initiatives.
Education, Certifications
Bachelor of Pharmacy or Doctor of Pharmacy degree or health-related field
Master’s in Business Administration is preferred
Registered with Saudi Commission for Health Specialists is preferable
Certificate in insurance or any other equivalent certification is preferable
Proficient in oral and written English language (Intermediate)
Experience
8+ years of relevant experience which has 3 years in formulary management
Experience in monitoring, inspection, enablement
Excellent verbal and written communication skills sufficient to prepare own correspondence and interact with members and providers in provision of advice and guidelines
Ability to work cross functionally both in and out of the organization to accomplish goals
Knowledge of formulary & utilization management techniques
Knowledge of pharmacy operations, trends and management techniques
Knowledge of pharmaceuticals and disease states to provide advice and consultation to providers and members, and recommend changes to the formulary
Possess research and analytical skills sufficient to provide problem resolution and consultation to providers
Previous experience in insurance sector or healthcare sector is a must