Director, Pharmacy Coverage Reviews

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🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🔴 Lead

💊 Pharmacist

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BlueCross BlueShield of Tennessee

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1952

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

BlueCross BlueShield of Tennessee is a leading health plan provider in Tennessee, serving 3. 4 million members. The company is committed to creating a workforce where everyone is valued, respected, and part of the team, emphasizing diversity and inclusion. They offer a range of career opportunities, including internships through their BlueBridge program, enabling new professionals to transition from college to work. BlueCross BlueShield of Tennessee also focuses on providing exceptional customer service and community care, striving to make a difference in the healthcare industry. It is an independent licensee of the Blue Cross Blue Shield Association and a qualified health plan issuer in the Health Insurance Marketplace.

📋 Description

• Direct day-to-day operations for prior authorization and appeals programs • Maintain and enforce clinical coverage policies in adherence with URAC, NCQA, and CMS standards • Lead and mentor managers and staff, setting performance expectations and improving service quality and turnaround times • Monitor utilization trends, turnaround metrics, and appeal outcomes to identify improvement opportunities and support affordability initiatives • Partner with clinical strategy, pharmacy benefit management, and compliance teams to align coverage review operations with enterprise goals • Ensure documentation and review activities meet internal and external audit standards and support enterprise compliance • Drive enhancements through technology adoption, workflow optimization, and best-practice integration

🎯 Requirements

• Doctor of Pharmacy Degree (PharmD) required • Minimum 8 years of clinical experience required • Minimum 6 years of practical experience in a managed care environment • Minimum 4 years of supervisory/leadership responsibilities required • Ability to lead coverage review operations and ensure compliance • Expertise in policy implementation and regulatory standards • Skill in data analysis for utilization trends and performance metrics • Strength in cross-functional collaboration for operational alignment • Leadership in driving process improvements and team development • Licensed in Tennessee to practice Pharmacy, or eligible for licensure in Tennessee to practice Pharmacy • Proficiency in the Microsoft Office suite, including Microsoft Teams • Strong organizational skills and ability to manage multiple assignments or projects simultaneously • Strong interpersonal abilities and oral and written communication skills • Ability to use AI-enabled tools responsibly

🏖️ Benefits

• Remote-first work arrangement • Remote positions available from across the U.S., excluding California, Massachusetts, New Hampshire, New Jersey, and New York • Relocation assistance may be available if the position requires residence in Chattanooga, TN • Microsoft Office suite and Microsoft Teams proficiency supported as part of the work environment • AI-enabled tools may be used responsibly to support everyday work