Job Description
Job Description Your Role The Prior Authorization (PA) team utilizes clinical knowledge to review authorization requests for coverage under the outpatient pharmacy benefit. The Pharmacist-Consultant will work as part of the pharmacy benefit Prior Authorization (PA) team to support the Blue Shield of California (BSC) Pharmacy and Therapeutics Committee (P&T) by ensuring that evidence based clinical decisions are implemented appropriately to provide a high-quality and cost-effective pharmacy benefit. The Pharmacist- Consultant (Drug Utilization Review Pharmacist) will report to the Drug Utilization Review (DUR) Pharmacist Manager.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Responsibilities Your Work In this role, you will:
- Support the clinical and operational implementation of P&T approved policies for the pharmacy benefit, for both the Commercial and Medicare lines of business
- Apply clinical expertise to PA reviews and work collaboratively with the PA and Call Center Teams to support access to safe, efficacious, and medically necessary medications
- Operate in compliance with all regulatory and accreditation requirements to ensure all requests are reviewed within regulatory required timeframes
- Serve as a resource to internal and external constituents regarding the Blue Shield drug formulary, medication policies and appropriate drug use
- Embrace BSC values by answering clinical and operational questions, participating in group discussions, and supporting other team members while working towards a collective goal
- Use clear and concise communications and on-brand messaging when communicating with providers or members
- Follow all corporate policies and procedures
- Operate in compliance with all regulatory and accreditation requirements, and corporate policies and procedures regarding the support access to safe, efficacious, and medically necessary medications
- Assist in preparing materials for audits and reports; complete projects as assigned
Qualifications Your Knowledge and Experience - Requires a Doctor of Pharmacy (PharmD) degree
- Requires a currently active and unrestricted California Registered Pharmacist (RPh) license
- Requires at least 2 years of experience in clinical pharmacy
- Requires experience working at a health plan (managed care, government payer, or academic)
- 1 year of prior authorization experience required
- Experience working with formulary and medication policies required
- Excellent oral and written communication skills
- Thorough knowledge of therapeutic use of medications
Hybrid Virtual Work This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
About the Team About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values: - Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
- Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
- For most teams, this means coming into the office two days per week.
- Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
- For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
Job Tags
Full time, Part time, Work at office, Local area, Work from home, Home office, 2 days per week