Sr. Director, Pharmacy - Prior Authorization & Call Center

Blue Shield of California • Oakland, CA

2d • Hybrid

About The Position

The Senior Director, Pharmacy Prior Authorization and Call Center leads the design, execution, and optimization of prior authorization and pharmacy call center processes at Blue Shield of California. Reporting to the Senior Vice President of Pharmacy Services, this role manages a team of more than 200 employees and works in collaboration with the Medical Director to support clinically appropriate, cost-effective, compliant patient care. The position partners across the organization and with vendors to optimize member access and affordability for medications covered under pharmacy and medical benefits across all lines of business.

The role calls for a leader who can build and sustain high-performing teams, develop leaders, foster continuous learning, and deliver results through creative and critical thinking. It is a hybrid position. Most teams work in the office two days each week; employees who live more than 50 miles from an office location will work with their manager to determine in-office time based on business needs.

Requirements

• Current, active, unrestricted California Registered Pharmacist (RPh) license.
• Doctor of Pharmacy (PharmD) degree from an accredited U.S. school of pharmacy.
• 12 years of prior experience in a managed care health plan, pharmacy benefit management company, or other relevant setting; in pharmacy prior authorization program and call center operations; and in developing and implementing strategic operational plans to optimize efficiency and cost outcomes.
• 6 years of people management experience with direct responsibility for supervising, coaching, and evaluating direct reports.
• Strong financial and business acumen, with the ability to use performance data to drive operational improvements.
• Excellent interpersonal, written, and verbal communication skills.
• Strategic and analytical thinking and data- and evidence-informed problem-solving skills.

Nice To Haves

• Prior experience in vendor management and oversight.
• Thorough knowledge of therapeutic drug use and available national guidelines.
• Knowledge of pharmacy benefits, formularies, and network programs for drugs covered under pharmacy and medical benefits.

Responsibilities

• Lead and manage the prior authorization team to meet clinical, regulatory, and business objectives.
• Lead and manage the pharmacy call center team, supporting inbound and outbound provider calls to coordinate members’ access to appropriate drug therapy.
• Implement and maintain medication coverage policies for drugs covered under pharmacy and medical benefits, promoting evidence-based coverage decisions.
• Work with analytics and business teams to evaluate prior authorization program outcomes and performance and identify opportunities for improvement.
• Develop and implement prior authorization vendor oversight programs and processes to ensure compliance with clinical and regulatory standards.
• Collaborate with Medical Directors, Appeals and Grievance, and care management teams to support evidence-based decisions, adherence to coverage policies, care coordination, and customer experience.
• Implement strategies and technology enhancements, such as automation and AI, to improve program effectiveness and operational efficiency.
• Participate in regulatory or quality audits involving utilization management program reviews.
• Build a high-performing team, promote leadership principles among managers, and foster a workplace where employees can do meaningful work.

What This Job Offers

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