Mgr, Pharmacy Network Integrity

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us.

We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

About the Role

Leads all program efforts and collaboration with applicable regulatory agencies associated with all Pharmacy Fraud, Waste, and Abuse program and efforts, i.e. NJ Medicaid Fraud Division, Federal Bureau of Investigation, Medicaid Fraud Control Unit, NJ Division of Medical Assistance and Health Services in efforts to ensure that the Pharmacy Fraud, Waste and Abuse program satisfies all key metrics for the program as established by senior leadership.

Lead the clinical oversight and collaboration efforts with the pharmacy audit vendor and site selection for all on-site retail pharmacy audits. Responsible for designing all necessary utilization management programming edits.

What You'll Do

• Design and revise on an ongoing basis all the necessary program elements and tools required to mitigate Pharmacy Fraud, Waste and Abuse.
• Leads all program efforts and collaboration with applicable regulatory agencies associated with all Pharmacy Fraud, Waste, and Abuse program and efforts, i.e. NJ Medicaid Fraud Division, Federal Bureau of Investigation, Medicaid Fraud Control Unit, NJ Division of Medical Assistance and Health Services in efforts to ensure that the Pharmacy Fraud, Waste and Abuse program satisfies all key metrics for the program as established by senior leadership.
• Responsible for ensuring that all program elements are in full compliance with all State, Federal and Division of Medical Assistance and Health Services (DMAHS) contractual and regulatory requirements on an ongoing basis.
• Develop and implement all necessary algorithms and programming required for staff to effectively identify potentially fraudulent pharmacy claims activity.
• Provide effective training to staff responsible for the review of all high dollar and seemingly aberrant Medicaid pharmacy claim payments for subsequent reconciliation and recovery.
• Educate and lead staff on the appropriate methodology and approach for the pharmacy desktop audit program, and subsequent reporting and presentation of program impact to Sr. leadership on an ongoing basis.
• Ongoing identification of necessary POS Rx system edits designed to mitigate future aberrant claims and unnecessary claims expenditures. Provide leadership, education and training to staff on methodology utilized for this purpose.
• Lead the clinical oversight and collaboration efforts with the pharmacy audit vendor and site selection for all on-site retail pharmacy audits.
• Design a process to be utilized to identify and coordinate the suspension of claim payments for all excluded and debarred providers. Provide leadership, education, and training to staff on logic utilized for this purpose.
• Accountability for review of pharmacy J and Q code payments made to physicians and hospitals to ensure reasonableness of quantities billed and amounts paid. Ongoing and timely reporting of aberrant claims identified to the Director of GP Operations to allow for any necessary claims adjustment.
• Responsible for designing all necessary utilization management programming edits i.e. Quantity/dosing thresholds in the claims payment system to ensure drug wastage is minimized.
• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.

What You Bring

• Education/Experience: Bachelor degree is required in Pharmacy or Pharm D from an accredited college or university.
• Requires a minimum of 5 years of recent practice as a Registered Pharmacist, preferably in New Jersey in a retail, PBM, managed care or auditing environment.
• Requires a minimum of three (3) years prior pharmacy auditing experience.
• Additional licensing, certifications, registrations: Active unrestricted NJ Pharmacist License Required.
• Knowledge: Requires private and government third party prescription program operations.
• Requires State of NJ Board of Pharmacy Regulations.
• Requires state and federal Controlled Drugs and Substances regulations.
• Requires Federal Pharmacy regulation including DESI and MAC policies.
• Skills and Abilities: Must be customer focused with effective ability to empathize.
• Demonstrated professional and ethical business practices, adherence to company standards code of conduct and conflict of interest, and a commitment to personal and professional development.
• Effective verbal and written communication skills including the ability to deliver highly technical and or clinical information to less technical and / or non-clinical individuals.
• Ability to effectively communicate policy and procedure to customers in an effort to inform and educate.
• Demonstrated ability to work well within a team.
• Proven time management skills.
• Ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.
• Demonstrated ability to work in a production focused environment.
• Proven ability to exercise sound judgment and strong problem solving skills.
• Proven ability to ask probing questions and obtain thorough and relevant information.
• Requires the ability to utilize a personal computer and applicable software.
• Strong negotiation skills.
• Travel: Hybrid Schedule - 1-2 days per week on-site
• Approximately 10-12 trips per year within New Jersey to vendor sites for audits
• Why Horizon?
• At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth.  We believe that when our people thrive, our communities do too.  If you are passionate about making an impact, we’d love to hear from you!

Disclaimer:

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.