Mgr, Pharmacy Network Integrity

Horizon Healthcare Services•Hopewell, NJ

1d•Hybrid

About The Position

The Manager, Pharmacy Network Integrity leads the Pharmacy Fraud, Waste, and Abuse program, including collaboration with regulatory agencies such as the NJ Medicaid Fraud Division, Federal Bureau of Investigation, Medicaid Fraud Control Unit, and NJ Division of Medical Assistance and Health Services. The role ensures the program meets key metrics established by senior leadership and complies with applicable state, federal, contractual, and regulatory requirements. The position designs and maintains program tools, algorithms, utilization-management edits, and processes to identify and mitigate potentially fraudulent, wasteful, or aberrant pharmacy claims. It provides oversight of pharmacy audits, including collaboration with the pharmacy audit vendor and selection of retail pharmacy sites for on-site audits. The manager also trains and leads staff, oversees reporting and recovery-related activities, and manages staff performance and compensation. The position follows a hybrid schedule, with 1–2 days per week on-site and approximately 10–12 trips per year within New Jersey to vendor sites for audits. Horizon employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

Bachelor’s degree in Pharmacy or Pharm.D. from an accredited college or university.
At least 5 years of recent practice as a Registered Pharmacist; New Jersey experience in retail, PBM, managed care, or auditing is preferred.
At least 3 years of prior pharmacy auditing experience.
Active, unrestricted New Jersey Pharmacist License.
Knowledge of private and government third-party prescription program operations.
Knowledge of New Jersey Board of Pharmacy regulations.
Knowledge of state and federal controlled drugs and substances regulations.
Knowledge of federal pharmacy regulations, including DESI and MAC policies.
Customer-focused approach and ability to empathize.
Professional and ethical business practices, adherence to company standards, code of conduct, and conflict-of-interest requirements, and commitment to professional development.
Effective verbal and written communication, including explaining technical or clinical information to less technical or non-clinical audiences.
Ability to communicate policies and procedures to customers to inform and educate them.
Ability to work effectively within a team.
Time-management skills and ability to manage multiple priorities, produce timely and accurate work, and respond with urgency as needed.
Ability to work in a production-focused environment.
Sound judgment and strong problem-solving skills.
Ability to ask probing questions and obtain thorough, relevant information.
Ability to use a personal computer and applicable software.
Strong negotiation skills.
Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Nice To Haves

Recent pharmacy practice in New Jersey, preferably in a retail, PBM, managed care, or auditing environment.

Responsibilities

Design and continually revise program elements and tools to mitigate Pharmacy Fraud, Waste, and Abuse.
Lead program efforts and collaborate with relevant regulatory agencies to ensure the program meets senior leadership’s key metrics.
Ensure ongoing compliance with state, federal, DMAHS contractual, and regulatory requirements.
Develop and implement algorithms and programming to help staff identify potentially fraudulent pharmacy claims activity.
Train staff who review high-dollar and apparently aberrant Medicaid pharmacy claim payments for reconciliation and recovery.
Educate and lead staff in pharmacy desktop audit methods, reporting, and presentation of program impact to senior leadership.
Identify necessary point-of-sale prescription system edits to mitigate future aberrant claims and unnecessary expenditures, and train staff on the methods used.
Provide clinical oversight and collaborate with the pharmacy audit vendor; select retail pharmacy sites for on-site audits.
Design a process to identify and coordinate suspension of claim payments for excluded and debarred providers, and train staff on the related logic.
Review pharmacy J and Q code payments to physicians and hospitals for reasonableness of quantities billed and amounts paid.
Report identified aberrant claims promptly to the Director of GP Operations to allow necessary claims adjustments.
Design utilization-management programming edits, including quantity and dosing thresholds, to minimize drug wastage.
Manage, develop, and train staff; set and monitor goals; conduct annual performance reviews; and administer staff salaries.