Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,400 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
Provide utilization management for drug therapies including; review of prior authorization requests to make determinations for drug therapy according to member benefits and coverage criteria, creation and maintenance of Pharmacy and Medical drug therapy guidelines, development of clinical criteria for review of non-formulary or non-preferred drug requests, and determination and maintenance of applicable prescription limitations (age, gender, quantity, etc.) Level 2: Provide review and strategy for pharmacy clinical programs.
- Review prior authorization requests and make determinations for drug products according to member benefits, established treatment protocols and clinical criteria
- Make coverage determinations within the defined turnaround times and meet regulatory requirements
- Responsible for clinical criteria including analysis, monitoring of the industry trends and assist in development of the criteria for the Pharmacy and Therapeutics Committee
- Develop and design clinical edits to adjudicate claims and enhance drug utilization
- Provide clinical guidance and support to the assigned pharmacy technicians
- Develop and review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design
- Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy procedures
- Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
- Assist to develop and design specialty medication clinical edits for claims adjudication and enhanced drug utilization review
- Provide clinical guidance and support for systematic reviews of prescription claims to meet strategic initiatives
- Reviews policies and procedures related to pharmacy issues
- Works in collaboration with Prior Authorization Supervisor to help with workflows and operational efficiencies
- Provides input into pharmacy technician functions to improve clinical decision making
- Reviews and resolves complaints made by members and providers regarding Prior Authorization, formulary or pharmacy services
- Participates in support of the Pharmacy and Therapeutics Meeting to review and keep current Drug Formulary
- Knowledge of utilizing LexiComp, Facts and Comparisons, Micromedex, UptoDate, National guidelines, NCCN etc.
- Collaborate to create clear communication to members and/or providers on prior authorization determinations
- Work in partnership with pharmacy staff to assist in the implementation of utilization management programs
- Educate pharmacy staff on specific utilization management guidelines and processes
- Collaborate with the Pharmacy Director to determine clinical edits to adjudicate claims and enhance drug utilization (e.g. create and maintain coverage policies for quantity limits, step therapies, age/gender limitations)
- Continuously work to streamline and improve the quality of the drug utilization management strategy process and Prior Authorization process
- Be available as a clinical resource to all BCBSSAZ internal staff regarding medication therapy
- Assist in the training and mentoring of pharmacy students
- Support the determination, appeal, and grievance process for the retail, mail order, specialty, and medical prescription benefits
LEVEL 2 – ADDITIONAL JOB FUNCTIONS
This would be project based and in addition to prior authorization reviews. Provide program development, program clinical review and strategy for pharmacy clinical program initiatives. These include creating pharmacy medication plans, executing plans and tracking progress of the plans. Candidates will need to have experience working with executives and reporting progress to executive level personnel. Current programs to start are below:
- Opioid Management
- Perform retro review of members on high dosages of opioids and/or taking in combination with benzodiazepines
- Work closely with the prescriber to draft a plan to lower dosage of opioids, benzodiazepines
- Execute plans and track progress
- Educate top opioid prescribers about CDC guidelines on Opioid Prescribing and Medication Assisted Treatment (MAT)
- Management of High Cost Utilizers
- Monitor high cost utilizers on both pharmacy and medical side
- Work with prescribers to do medication reconciliation
- Execute MD plans and track progress
- Work with prescribers to provide other clinically equivalent but cost effective alternatives
- Behavioral Health Management
- Provide medication reconciliation for members utilizing multiple behavioral health medications
- Work with the prescriber to draft a plan to deprescribe unnecessary medications
- Execute plan and track progress
- Work closely with case management to assist members attain their full potential
DEMONSTRATES EFFECTIVE MANAGEMENT SKILLS:
- Motivates and manages staff to ensure that performance standards are met or exceeded.
- Ensures that adequate in-service education is available to staff members.
- Demonstrates the ability to make decisions, take appropriate action and follow tasks through to completion.
- Recognizes and analyzes the implications of new situations and develops workable solutions to maintain productivity and morale.
- Acts as a role model in demonstrating the customer service standards of the Organization.
- Demonstrates a commitment to personal growth and development by participating in external activities related to professional goals.
- Responds cooperatively to managers and staff members in other departments to promote teamwork.
- Attends administrative meetings as appropriate and contribute ideas for improving efficiency, productivity and customer satisfaction.
- Attends all mandatory education and training courses.
- Maintain effective working relationships to ensure teamwork in achieving corporate goals.
- Participate in quality initiatives; including functions that support audits, reporting, evaluation of quality opportunities and concerns, and creation and implementation of corrective actions as requested.
- Coordinate activities between multiple divisions to achieve desired results.
- The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
- Perform all other duties as assigned.
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.