Mgr, Pharmacy Network Integrity

Horizon Blue Cross Blue Shield of New Jersey•Newark, NJ

4d•$109,600 - $149,625•Hybrid

About The Position

The Manager, Pharmacy Network Integrity leads Pharmacy Fraud, Waste, and Abuse program efforts and coordination with applicable regulatory agencies, including 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 program performance meets key metrics established by senior leadership and that program elements comply with applicable state, federal, and DMAHS contractual and regulatory requirements. The manager designs and revises program elements, algorithms, utilization-management edits, and other tools to identify and mitigate potentially fraudulent, aberrant, or unnecessary pharmacy claims. The position oversees pharmacy desktop auditing, reviews high-dollar and aberrant Medicaid pharmacy claim payments, coordinates retail pharmacy audits with the pharmacy audit vendor, and provides staff training and leadership. It also manages staff, performance goals and reviews, and salaries. The position follows a hybrid schedule, with 1–2 days per week onsite, and entails approximately 10–12 trips per year within New Jersey to vendor audit sites. Horizon employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

Bachelor’s degree in Pharmacy or PharmD from an accredited college or university.
At least 5 years of recent practice as a Registered Pharmacist.
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 personal and professional development.
Effective verbal and written communication, including the ability to explain 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, deliver timely and accurate work, and respond urgently when 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.

Nice To Haves

Pharmacy practice experience in New Jersey is preferred.
Experience in a retail, PBM, managed care, or auditing environment is preferred.

Responsibilities

Design and continually revise program elements and tools to mitigate Pharmacy Fraud, Waste, and Abuse.
Lead program efforts and collaborate with applicable regulatory agencies to meet program metrics established by senior leadership.
Ensure program elements comply with state, federal, and 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 seemingly aberrant Medicaid pharmacy claim payments for reconciliation and recovery.
Educate and lead staff on pharmacy desktop audit methods and on reporting and presenting 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 methodology.
Lead clinical oversight and collaboration with the pharmacy audit vendor and select sites for on-site retail pharmacy 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 support any necessary claim 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.