- Pay Range for California: $212630.00 to $318890.00
- Pay Range for Bay Area: $239692.00 to $359476.00
- Note: Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.
- Role can be filled by a candidate requiring sponsorship: No
Your Role
The Blue Shield of California (BSC) Pharmacy team is passionate about making a meaningful impact by reimagining pharmacy care. Ensuring every member has safe, equitable access to sustainably affordable pharmacy benefits is at the heart of everything we do. The Senior Director, Pharmacy Prior Authorization and Call Center will report to the Senior Vice President of Pharmacy Services at BSC. In this role you will manage a team of over 200 employees and in collaboration with the Medical Director, be responsible for designing, executing, and optimizing prior authorization and call center processes to ensure clinically appropriate, cost effective, and compliant patient care. You will work cross functionally and partner with vendors as appropriate to optimize patient access while supporting affordability of medications covered under pharmacy and medical benefits for all lines of businesses.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Responsibilities
Your Work
In this role, you will:
- Lead and manage the prior authorization team to meet clinical, regulatory and business objectives of the prior authorization program
- Lead and manage the pharmacy call center team to support inbound and outbound provider calls to coordinate access to appropriate drug therapy for members
- Implement and maintain medication coverage policies for drugs in the pharmacy and medical benefits that promotes evidence-based coverage decisions
- Collaborate with analytics and business areas to drive evaluation of prior authorization program outcomes and performance, and identify opportunities to improve
- Develop and implement Prior Authorization vendor oversight program and process to ensure compliance with expected clinical and regulatory standards
- Collaborate cross-functionally with BSC Medical Directors, Appeals and Grievance and care management teams to share accountability for evidence-based decision-making, promote adherence to BSC coverage policies, facilitate care coordination and optimize customer experience
- Implement strategies and technology enhancements (e.g. automation, AI) to improve program effectiveness and operational efficiency
- Participate in regulatory or quality audits that involve the review of utilization management program
- Build a high performing team and drive leadership principles among managers, and foster a great workplace to do meaning work
Qualifications
Your Knowledge and Experience
- Requires a current active and unrestricted California Registered Pharmacist (RPh) license
- Requires a Doctor of Pharmacy (PharmD) degree from an accredited school of pharmacy in the U.S.
- Requires 12 years of prior experience in: a managed care health plan or pharmacy benefit management companies or other relevant settings; pharmacy prior authorization program and call center operations; developing and implementing strategic operational plans to optimize efficiency and cost outcomes
- Requires 6 years of people management experience
- Prior experience in vendor management and oversight preferred
- Thorough knowledge regarding therapeutic use of drugs and available national guidelines preferred
- Knowledge of pharmacy benefits, formulary, network programs for drugs covered in pharmacy and medical benefits preferred
- Strong financial and business acumen with the ability to leverage performance data to drive operational improvements
- Excellent interpersonal, written & verbal communication skills
- Strategic and analytic thinking; problem-solving skills informed by data and evidence
Hybrid
This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
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