Director, Pharmacy Coverage Reviews

BlueCross BlueShield of Tennessee • Chattanooga, TN

1d

About The Position

Direct day-to-day operations for prior authorization and appeals programs, ensuring efficient, compliant, and member-focused service delivery. Maintain and enforce clinical coverage policies, ensuring adherence to regulatory and accreditation standards (URAC, NCQA, CMS). Lead and mentor managers and staff, setting clear performance expectations and fostering continuous improvement in service quality and turnaround times. Monitor utilization trends, turnaround metrics, and appeal outcomes to identify improvement opportunities and support affordability initiatives. Partner with clinical strategy, pharmacy benefit management, and compliance teams to align coverage review operations with enterprise goals. Ensure documentation and review activities meet internal and external audit standards and support enterprise compliance efforts. Drive enhancements in coverage review processes through technology adoption, workflow optimization, and best practice integration.

Requirements

• Doctor of Pharmacy Degree (PharmD) required
• Minimum 8 years Clinical experience required
• Minimum 6 years Practical experience in a managed care environment
• Minimum 4 years of supervisory/leadership responsibilities required
• Ability to lead coverage review operations and ensure compliance
• Expertise in policy implementation and regulatory standards
• Skill in data analysis for utilization trends and performance metrics
• Strength in cross-functional collaboration for operational alignment
• Leadership in driving process improvements and team development
• Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy

Responsibilities

• Direct day-to-day operations for prior authorization and appeals programs, ensuring efficient, compliant, and member-focused service delivery.
• Maintain and enforce clinical coverage policies, ensuring adherence to regulatory and accreditation standards (URAC, NCQA, CMS).
• Lead and mentor managers and staff, setting clear performance expectations and fostering continuous improvement in service quality and turnaround times.
• Monitor utilization trends, turnaround metrics, and appeal outcomes to identify improvement opportunities and support affordability initiatives.
• Partner with clinical strategy, pharmacy benefit management, and compliance teams to align coverage review operations with enterprise goals.
• Ensure documentation and review activities meet internal and external audit standards and support enterprise compliance efforts.
• Drive enhancements in coverage review processes through technology adoption, workflow optimization, and best practice integration.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Ph.D. or professional degree