Pharmacy Compliance & Fraud Reduction Lead

Horizon Blue Cross Blue Shield of New Jersey; Newark (NJ); Hybrid; USD 110,000 - 150,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement plans

Generous PTO

Incentive plans

Wellness programs

Tuition reimbursement

Paid volunteer time off

Job summary

Horizon Blue Cross Blue Shield of New Jersey seeks an experienced Pharmacist leader to oversee the Pharmacy Fraud, Waste and Abuse program, coordinate with regulators, and design utilization management edits. This role includes staff training and oversight of on-site audits, ensuring compliance with state and federal requirements.

Senior responsibilities include leadership of clinical oversight, developing staff, and managing auditing processes across NJ with periodic travel.

Qualifications

• Bachelor degree is required in Pharmacy or Pharm D from an accredited college or university.
• Minimum 5 years of recent practice as a Registered Pharmacist, preferably in New Jersey in a retail, PBM, managed care or auditing environment.
• Minimum 3 years prior pharmacy auditing experience.
• Active unrestricted NJ Pharmacist License Required.
• Knowledge of State of NJ Board of Pharmacy Regulations and Federal Pharmacy regulation including DESI and MAC policies.

Responsibilities

• Lead program efforts and collaboration with regulatory agencies to ensure metrics are met.
• Design and implement utilization management programming edits to reduce waste.
• Provide training to staff on reviewing high-dollar Medicaid pharmacy claims.
• Oversee pharmacy audit processes and site selection for on-site audits.
• Ensure compliance with state and federal regulatory requirements.

Skills

Customer-focused

Effective communicator

Problem solving

Team player

Time management

Detail oriented

Education

Pharmacy degree (PharmD) or BS Pharmacy

Job description

Horizon Blue Cross Blue Shield of New Jersey seeks an experienced Pharmacist leader to oversee the Pharmacy Fraud, Waste and Abuse program, coordinate with regulators, and design utilization management edits. This role includes staff training and oversight of on-site audits, ensuring compliance with state and federal requirements.

Senior responsibilities include leadership of clinical oversight, developing staff, and managing auditing processes across NJ with periodic travel.