Dir, Payment Model Evolution

About the position The Pharmacy Specialist II position is a critical role within Horizon BCBSNJ, responsible for managing prior authorization requests from pharmacists, physicians, and patients. This position plays a vital part in the coordination of Pharmacy Services activities, which include analyzing claim utilization, designing prescription plans, generating ad-hoc reports, and handling correspondence related to special projects. The specialist must ensure compliance with organizational goals and regulatory standards while maintaining high performance levels. Additionally, this role serves as a backup for the department supervisor when necessary. In this role, the Pharmacy Specialist II will process prior authorizations by evaluating the medical necessity and appropriateness of specific drugs based on established medical criteria. The specialist will engage directly with members, physician office staff, pharmacies, and internal stakeholders to address eligibility, coverage determinations, and claims issues. Recommendations for improving departmental efficiency, accuracy, and productivity will be a key responsibility, along with processing appeals, complaints, and compliance-related issues. The specialist will also be tasked with researching, recommending, and implementing procedures to enhance operational efficiency. This includes providing pharmaceutical information, such as drug pricing, to support various business units and service areas. The role involves responding to ad hoc requests for information or reports from stakeholders and participating in training sessions for clients, members, and employees to ensure a comprehensive understanding of pharmacy services programs and operations. Monitoring daily workflow metrics and coaching new employees are also essential functions of this position, ensuring that requests from physicians and members are resolved promptly. Responsibilities • Process prior authorizations received via the help line, evaluating medical necessity for specific drugs based on medical criteria. , • Interact directly with members, physician office staff, pharmacies, and internal stakeholders for eligibility and claims issues. , • Provide recommendations to increase efficiency, accuracy, and productivity in the department. , • Process appeals, complaints, executive inquiries, and compliance-related issues. , • Research, recommend, monitor, develop, and implement procedures to enhance departmental efficiency. , • Process ad hoc requests for information or reports from various stakeholders. , • Participate in client member and employee training to ensure understanding of pharmacy services programs. , • Monitor day-to-day workflow metrics and formulate strategies for improvement. , • Coach and train new employees and act as backup to the Pharmacy Benefit Analyst or immediate supervisor. , • Assist in resolving Physician/Member requests in a timely manner. Requirements • Bachelor's degree in Health Care Management, Business, or Pharmaceutical Administration preferred. , • Minimum of two years of experience in third-party prescription program claim adjudication required. , • Minimum of two years of experience as a Pharmacy Utilization Management Specialist required. , • Prior customer service/service quality initiative experience required. , • Pharmacy Certification required. , • Knowledge of popular brand and generic drug names required. , • Knowledge of third-party prescription program claim adjudication required. , • Working knowledge of managed care principles required. , • Knowledge of common medical terminology required. , • Understanding of National Drug Code (NDC) required. , • Knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation required. , • Ability to utilize a personal computer and applicable software required. , • Effective verbal and written communication skills required. , • Ability to work well within a team and deliver technical information to less technical individuals required. , • Proven time management skills required. , • Ability to manage multiple priorities and deliver timely and accurate work products required. , • Ability to exercise sound judgment and strong problem-solving skills required. Nice-to-haves Benefits • Comprehensive health benefits (Medical/Dental/Vision) , • Retirement Plans , • Generous PTO , • Incentive Plans , • Wellness Programs , • Paid Volunteer Time Off , • Tuition Reimbursement Apply Job!