Senior Clinical Pharmacist

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

• Required PharmD

Experience

• Required 5 + Years pharmacy residency or 3-5 years of work experience in the Health Plan or Pharmacy benefit manager environment

Knowledge Skills and Abilities

• Knowledge of Medicare Part D, formulary and utilization-management requirements, delegated oversight, compliance, and audit readiness.
  
• Strong clinical judgment, analytical, quality-control, communication, and cross-functional collaboration skills.
  
• Excellent interpersonal skills and the ability to work with all levels of the Association, Plans, government agencies and vendors.
  
• Communication skills, written and oral.
  
• Technical proficiency with information technologies (Microsoft software applications e.g. Excel).
  
• Preferred: Demonstrates AI literacy and an understanding of generative AI tools, including appropriate business applications and limitations.

Certifications & Licenses

• Required: PHARMD - Licensed Pharmacist - Various PharmD required and licensed pharmacist to perform clinical duties

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.

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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.

Welcome

Begin your career at Blue Cross Blue Shield Association (BCBSA) by exploring currently opportunities and starting your application. It’s easy! After reviewing our open positions, apply to the roles that meet your requirements and ours too. You can keep track your progress in the selection process and review new postings too. Thanks for interest in joining Team BCBSA!

About Us

At Blue Cross Blue Shield Association (BCBSA), we are a national association of 33 independent, community-based and locally operated Blue Cross Blue Shield companies and we are driven by purpose. Join the team who supports the nation's largest healthcare network, providing coverage to nearly one in three Americans as we relentlessly pursue affordable healthcare and ensure peace of mind for the people we serve. Be part of our storied history of innovation as we advance well-being and health equity. Experience a culture that is built on our core values, connection, work-life flexibility, well-being, and a commitment to our community. If you thrive at a company that values inclusivity, accountability, courage, teamwork, and respect, we're glad you found us!