Blue Cross NC · 8 hours ago
Director of UM Operations and Compliance
United States
Full-time
Remote
Lead/Staff, Director/Executive
$132K/yr - $251K/yr
10+ years exp
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Responsibilities
Direct, manage and lead efforts that define and enable strategic and operational priorities for the Pharmacy group.
Lead staff responsible for accomplishing goals related to pharmacy operations, clinical and specialty pharmacy programs, opportunity analysis, solution design, provider/payer integration and vendor evaluation and management.
Provides expertise and insights for new services, operational improvements, and partnerships to drive pharmacy cost reductions and quality of care initiatives.
Champion innovation while identifying pharmacy related opportunities and collaborations that drive value for Blue Cross NC members.
Evaluates emerging pharmacy industry trends and the strategic needs of the department as it relates to overall business objectives.
Translates strategy into defined tactics, programs/projects, priorities and timelines and ensures alignment with Healthcare objectives and enterprise goals.
Participates in the development of departmental strategic plans and objectives to improve quality of care and achieve medical expense goals.
Understands the evolving medication therapy space and develops strategies around traditional, specialty and gene therapies.
Directs the management of operational aspects of pharmacy services.
Oversees day-to-day operations of pharmacy benefits management and other related vendors to meet the needs of the membership and remain responsive to the company’s needs to achieve customer expectations and financial and performance targets.
Directs, manages, and/or supports implementation of corporate projects that impact operational aspects of pharmacy services and its vendors.
Evaluate and manage new and/or existing vendors and solution partners to align to BCNC’s strategic direction.
Develops economic or quality models to evaluate new vendors.
Directs the development and oversight of specialty pharmacy initiatives and pharmacy utilization management programs and policies to manage trend targets and reduce medical expense.
Provides oversight over Medicare Part D Star and pharmacy related HEDIS measures.
Manages and oversees the development of and monthly maintenance of cost-effective formularies.
Identifies new clinical initiatives and modifications to current programs and processes to improve the company’s competitive position.
Ensures programs are compliant in accordance with regulations of State, Federal, and other accrediting bodies and ensures corrective action plans are implemented.
Represents the Pharmacy department at internal meetings by active participation in cross functional organizational committees ensuring corporate fitness and market position.
Represent BCNC through delivery of presentations, speaking engagements and participation at PBM meetings/committees or external customer meetings as needed.
Drive leadership in project planning, designing and implementing innovative solutions around medication management.
Evaluation of investment/partnership opportunities.
Qualification
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Required
Bachelor’s degree and 10 years of experience in pharmacy benefits management, managed care, and/or strategic or product development.
OR PharmD/relevant Master’s degree (MBA/MHA) with 8 years of experience as stated above.
5 years of leadership experience, leading people and/or complex, cross divisional projects or programs.
For some positions, a current pharmacy license is required.
Benefits
Annual Incentive Bonus
401(k) with employer match
Paid Time Off (PTO)
Competitive health benefits and wellness programs
Company
Blue Cross NC
It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way.
5001-10000 employees
H1B Sponsorship
Blue Cross NC has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2023 (2)
2022 (5)
2021 (7)
2020 (11)
Funding
Current Stage
Late StageLeadership Team
Priscilla Alfaro
VP- Payment Integrity
Company data provided by crunchbase
