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Washington, District of Columbia, United States
Hybrid
A career with the Blue Cross Blue Shield Association allows you to be part of the organization that supports Blue Cross and Blue Shield companies nationwide. We seek to improve health care quality, affordability, and accessibility for all Americans, and we want you to join the team!
Driven by our North Star, to expand access to high-quality, affordable care for every community we serve, we foster a culture grounded in collaboration, accountability, and continuous improvement. Our people experience is built on meaningful work, competitive total rewards, and opportunities for growth, empowering you to make an impact while thriving both professionally and personally.
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This role supports the Federal Employees Program Part D/Employer Group Waiver Program pharmacy benefit in all clinical pharmacy functions including but not limited to formulary development, coverage determination and appeals, prior approval, and utilization process maintenance. Provides clinical and plan-sponsor oversight for the Federal Employees Program Medicare Prescription Drug Program/Employer Group Waiver Plan. The role oversees delegated clinical functions, formulary administration, Centers for Medicare & Medicaid Services reporting, compliance, audit readiness, and coordination with the Pharmacy Benefit Manager and internal stakeholders.- Serves as the clinical subject matter expert for Medicare Part D benefit design, formulary administration, supplemental wrap coverage, utilization management, and coverage determinations.
- Oversees delegated Pharmacy Benefit Manager clinical functions, performance, issues, corrective actions, and follow-up activities. Reviews formulary and utilization-management materials, coverage determination and appeals, including prior authorization, step therapy, quantity limits, transition requirements, and formulary changes.
- Responsible for reviewing, editing and completing Employer Group Waiver Program Medicare submissions, formulary, Pharmacy and Therapeutics modules, transition supply etc., and review and downloading patient safety and other requires files though the Health Plan Management System portal.
- Supports audit readiness, evidence validation, remediation tracking, and clinical quality-control reviews. Reviews Part B versus Part D coverage requirements and supports accurate benefit determinations and member communications. Develops and maintains Medicare PDP oversight policies, procedures, controls, and process documentation
- Provides support to internal pharmacy workgroups. Provides clinical guidance for presentations, plan education, executive updates, Office of Personnel Management responses, and cross-functional initiatives.
- Participates in Medicare P&T and utilization-management activities and evaluates the impact of clinical and benefit changes.
The posting range for this position is:
115,900.00 - 168,025.00
Qualifications:
Education
Experience
Knowledge Skills and Abilities
Certifications & Licenses
Extra Posting Information:
Experience that is indicative of the ability to understand how health care and patient care is delivered and how health care professionals interact in the health care environment. Experience with drug utilization review and formulary programs.
#LI-Hybrid
The posted salary range is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range and this hiring range may also be modified in the future. A candidate’s position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for annual bonus incentive pay.
We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
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NOTICE OF USE OF ARTIFICIAL INTELLIGENCE
Blue Cross and Blue Shield Association (“BCBSA”) is committed to ensuring compliance with federal, state, and local laws governing the use of technology in the employment context. BCBSA uses artificial intelligence (“AI”) tools to assist with our recruitment process. All hiring decisions remain subject to human review and oversight.