Manager, Pharmacy Network Integrity

Horizon Connect @ Wall BCBSNJ

. Lead all program efforts and collaborate with applicable regulatory agencies for the Pharmacy Fraud, Waste, and Abuse program .

Posted 10/22/2026full-timeUnited StatesMid-LevelSenior💰 $109,600 - $149,625 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Pharmacy Fraud, Waste, and Abuse program management, including compliance with regulatory requirements and effective staff training. Proficient in auditing pharmacy claims and implementing algorithms to identify fraudulent activities.

Highest-signal resume keywords

Pharmacy Fraud, Waste, And Abuse Program ManagementPharmacy Auditing ExperienceActive Unrestricted NJ Pharmacist LicenseKnowledge Of State And Federal Pharmacy RegulationsEffective Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Algorithm DevelopmentClaims ReviewUtilization Management ProgrammingPOS Rx System EditsPharmacy Desktop Audit ManagementData AnalysisRegulatory ComplianceClinical Oversight

Soft Skills

Strong Negotiation SkillsAbility To Manage Multiple PrioritiesEffective Verbal And Written Communication

Tools & Technologies

Personal ComputerApplicable Software

Certifications & Qualifications

Bachelor Degree In PharmacyPharm DActive Unrestricted NJ Pharmacist License

Industry Keywords

Pharmacy RegulationsControlled Drugs And Substances RegulationsThird Party Prescription Program OperationsMedicaid Pharmacy ClaimsRetail Pharmacy Audits

About the role

Key responsibilities & impact

Lead all program efforts and collaborate with applicable regulatory agencies for the Pharmacy Fraud, Waste, and Abuse program
Ensure the Pharmacy Fraud, Waste, and Abuse program satisfies key metrics established by senior leadership
Design and revise program elements and tools to mitigate Pharmacy Fraud, Waste, and Abuse
Ensure program elements comply with State, Federal, and DMAHS contractual and regulatory requirements
Develop and implement algorithms and programming to identify potentially fraudulent pharmacy claims activity
Train staff responsible for reviewing high-dollar and aberrant Medicaid pharmacy claim payments for reconciliation and recovery
Lead the pharmacy desktop audit program and report program impact to senior leadership
Identify and coordinate POS Rx system edits to mitigate aberrant claims and unnecessary expenditures
Provide clinical oversight and collaborate with the pharmacy audit vendor; select sites for on-site retail pharmacy audits
Design processes to suspend claim payments for excluded and debarred providers
Review pharmacy J and Q code payments to physicians and hospitals for reasonableness
Report aberrant claims to the Director of GP Operations for necessary claims adjustment
Design utilization management programming edits, including quantity/dosing thresholds, to minimize drug wastage
Manage, develop, and train staff; develop and monitor goals; conduct annual performance reviews; administer staff salaries

Requirements

What you’ll need

Bachelor degree is required in Pharmacy or Pharm D from an accredited college or university
Minimum of 5 years of recent practice as a Registered Pharmacist, preferably in New Jersey, in a retail, PBM, managed care or auditing environment
Minimum of three (3) years prior pharmacy auditing experience
Active unrestricted NJ Pharmacist License Required
Knowledge of private and government third party prescription program operations
Knowledge of State of NJ Board of Pharmacy Regulations
Knowledge of state and federal Controlled Drugs and Substances regulations
Knowledge of Federal Pharmacy regulation including DESI and MAC policies
Effective verbal and written communication skills, including ability to deliver highly technical or clinical information to less technical or non-clinical individuals
Ability to utilize a personal computer and applicable software
Strong negotiation skills
Ability to manage multiple priorities and deliver timely and accurate work products
Approximately 10-12 trips per year within New Jersey to vendor sites for audits

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Hybrid work schedule