Oscar is a new kind of insurer: we want to understand how the healthcare system works and develop ways to help our members navigate it more efficiently. We rely on a data-infused approach, deep clinical expertise, and a touch of creative insight to untangle complex health care cost problems.
About the Role:
The Pharmacy Team is responsible for developing, coordinating and executing a company-wide approach for the Oscar prescription drug benefit. As the Pharmaceutical Director you will support both ongoing operations and capability building - providing clinical perspective and a systematic approach for pharmacy-related operations. You will have the opportunity to critically evaluate data, serve as a ‘clinical eye’ and drive the incorporation of clinical perspectives into our analytical tools. The role reports to the Vice President of Clinical Operations and works in direct partnership with the Pharmaceutical Program Manager.
Pharmacy Vendor (PBM) Management:
- In partnership with data science and network, oversee and audit PBM clinical functions to ensure accurate application of utilization management criteria and correct administration of the benefit (according to Oscar custom requirements and regulatory requirements).
- Participate in development of Oscar’s Medicare Part D program, with a focus on clinical functions and regulatory compliance.
- In conjunction with data science, develop hypotheses and analyze pharmacy vendor data to determine opportunities for clinical and/or operational intervention, mitigation of fraud, waste and abuse and improvement of overall vendor performance.
- Support oversight of federal and state required pharmacy reporting, including timely submission and quality assessments.
- Resolve escalated pharmacy issues (administrative or clinical) from concierge staff and triage appropriately and see to resolution.
- Serve as a company-wide resource for all pharmacy related member or provider issues.
- Develop and implement Oscar clinical policies, procedures and workflows for both ACA and Medicare Advantage lines of business - ensuring compliance with both state and federal rules and negotiated contract requirements.
- Review escalated pharmaceutical utilization review cases and triage effectively to medical directors for final determinations.
Formulary Management and Analytical Support:
- Coordinate and improve Oscar’s formulary management process - maintaining clinically sound formularies for all product lines as outlined by Oscar policy, state, and federal regulatory guidelines.
- Support data science development of pharmaceutical data models - offering both clinical and design support based on knowledge of pharmaceuticals.
In this unique clinical role, you will be primarily working with data science, operations, and product teams. Your background should include:
- Pharmaceutical clinical literacy - formal clinical education (PharmD, PhD, M.D., etc..), with a bonus for significant practical training from prior work experience (pharmaceutical industry, consulting etc..).
- An engineering mindset - you know how to think systematically about problems, never ad hoc.
- Operational experience - comfort operating in a non-clinical environment and experience managing people (both formally and informally). Most clinicians at Oscar have a strong background outside of traditional clinical practice (finance, technology, consulting, health administration, etc..)
Additionally, we think it would be great if you are:
- Startup oriented - work experience in an entrepreneurial environment and a desire to move deliberately and quickly
- Healthcare experience - experience in health plan administration, managed care, or hospital administration settings including formulary development, P&T committee development, and PBM vendor management experience.
At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we work to cultivate an environment where exceptional people can be their most authentic selves and find both belonging and support. We're on a mission to change healthcare -- an experience made whole by your unique background and perspectives.
Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team ([email protected]) to make the need for an accommodation known.
Pay Transparency Policy: Oscar's Pay Transparency Policy ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.