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.

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 prior people management experience with direct responsibility for supervising, coaching, and evaluating direct reports
• 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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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

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

Skills:
Access Authorization, Artificial Intelligence (AI), Automation, Business Skills, Call Center Management, Call Center Operations, Call Centers, Clinical Practices/Protocols, Communication Skills, Compensation and Benefits, Cost Control, Cross-Functional, Customer Experience, Drug Therapy, Formulary, Health Plan, Interpersonal Skills, JavaScript, Leadership, Maintain Compliance, Managed Care, Medications, Network Programming, Operational Improvement, Operational Strategy, Operations Planning, Patient Care, People Management, Pharmacy, Presentation/Verbal Skills, Process Improvement, Program Evaluation, Regulations, Strategic Analysis, Strategic Planning, Team Lead/Manager, Technical Strategy, Utilization Management, Vendor/Supplier Management, Writing Skills

Blue Cross and Blue Shield Association

At the Blue Cross and Blue Shield Association (BCBSA), we provide business strategy, technical support and consulting expertise to 36 Blue Cross and Blue Shield companies across the nation, employing more than 1,000 of the best strategic thinkers in the industry. We are a Brand manager that sets quality control standards for the 36 independent companies that use the Blue Cross and Blue Shield Brands, and we serve as a trade association that represents these Blue companies. It is through our involvement that the Blues companies share a united vision and strategy while also benefiting from the local strength of all member companies.

Company Size:
2,000 to 2,499 employees

Industry:
Insurance

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