Mgr, Pharmacy Network Integrity

100 Horizon Healthcare Services, Inc; Hopewell (NJ); Híbrido; USD 110.000 - 150.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Descripción de la vacante

Horizon Blue Cross Blue Shield of New Jersey seeks a seasoned Pharmacist to lead Pharmacy Fraud, Waste and Abuse programs and collaborate with regulators. The role includes clinical oversight with auditing vendors and on-site audits, plus designing utilization management edits.

You will bring a NJ Pharmacist license, 5+ years of practice, and 3+ years in pharmacy auditing. Hybrid schedule with NJ travel and competitive benefits.

Formación

• Bachelor degree in Pharmacy or Pharm D from an accredited college or university.
• Active NJ Pharmacist License required.
• Minimum of 5 years as a Registered Pharmacist in retail, PBM, managed care or auditing.
• Minimum of 3 years pharmacy auditing experience.

Responsabilidades

• Lead all program efforts and regulatory collaboration for Pharmacy Fraud, Waste and Abuse.
• Oversee clinical oversight with the pharmacy audit vendor and site selection for on-site audits.
• Design utilization management programming edits.

Educación

Bachelor degree in Pharmacy or Pharm D

Active NJ Pharmacist License

Pharmacy auditing experience

Descripción del empleo

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in‑class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

About the Role Leads all program efforts and collaboration with applicable regulatory agencies associated with all Pharmacy Fraud, Waste, and Abuse program and efforts, i.e. NJ Medicaid Fraud Division, Federal Bureau of Investigation, Medicaid Fraud Control Unit, NJ Division of Medical Assistance and Health Services in efforts to ensure that the Pharmacy Fraud, Waste and Abuse program satisfies all key metrics for the program as established by senior leadership. Lead the clinical oversight and collaboration efforts with the pharmacy audit vendor and site selection for all on‑site retail pharmacy audits. Responsible for designing all necessary utilization management programming edits.

What You Bring

Education/Experience

• Bachelor degree is required in Pharmacy or Pharm D from an accredited college or university.
• Requires a minimum of 5 years of recent practice as a Registered Pharmacist, preferably in New Jersey in a retail, PBM, managed care or auditing environment.
• Requires a minimum of three (3) years prior pharmacy auditing experience.
• Additional licensing, certifications, registrations: Active unrestricted NJ Pharmacist License Required.
• Knowledge: Requires private and government third party prescription program operations.
• Requires State of NJ Board of Pharmacy Regulations.
• Requires state and federal Controlled Drugs and Substances regulations.
• Requires Federal Pharmacy regulation including DESI and MAC policies.

Skills and Abilities

• Must be customer focused with effective ability to empathize.
• Demonstrated professional and ethical business practices, adherence to company standards code of conduct and conflict of interest, and a commitment to personal and professional development.
• Effective verbal and written communication skills including the ability to deliver highly technical and or clinical information to less technical and / or non‑clinical individuals.
• Ability to effectively communicate policy and procedure to customers in an effort to inform and educate.
• Demonstrated ability to work well within a team.
• Proven time management skills.
• Ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.
• Demonstrated ability to work in a production focused environment.
• Proven ability to exercise sound judgment and strong problem solving skills.
• Proven ability to ask probing questions and obtain thorough and relevant information.
• Requires the ability to utilize a personal computer and applicable software.
• Strong negotiation skills.

Travel

Hybrid Schedule - 1-2 days per week on‑site Approximately 10-12 trips per year within New Jersey to vendor sites for audits

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!

Salary Range

Salary Range: $109,600 - $149,625 This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.

Benefits

Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

Disclaimer

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

About Us

We are the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too.

Our Mission

We empower our members to achieve their best health.

Our Vision

We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.