Manager, Pharmacy Network Integrity

Horizon Connect @ Wall BCBSNJ

. Lead all Pharmacy Fraud, Waste, and Abuse program efforts and collaboration with applicable regulatory agencies .

Posted 10/23/2026full-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, ensuring compliance with regulatory requirements while effectively training and leading staff. Proficient in developing algorithms for identifying fraudulent claims and conducting pharmacy audits.

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 AnalysisUtilization Management ProgrammingPharmacy Desktop AuditPOS Rx System EditsPharmacy Regulations KnowledgeData AnalysisPerformance MonitoringStaff TrainingRegulatory Compliance

Soft Skills

Effective Verbal CommunicationEffective Written CommunicationTime ManagementProblem-Solving SkillsNegotiation Skills

Tools & Technologies

Personal ComputerPharmacy Management Software

Certifications & Qualifications

Bachelor Degree In PharmacyPharm DActive Unrestricted NJ Pharmacist License

Industry Keywords

PharmacyManaged CareRetail PharmacyPBMMedicaidControlled Drugs And Substances RegulationsFederal Pharmacy RegulationDESI PoliciesMAC PoliciesThird Party Prescription Programs

About the role

Key responsibilities & impact

Lead all Pharmacy Fraud, Waste, and Abuse program efforts and collaboration with applicable regulatory agencies
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 POS Rx system edits to mitigate aberrant claims and unnecessary claims expenditures
Lead clinical oversight and collaboration with the pharmacy audit vendor and select sites for on-site retail pharmacy audits
Design processes to identify and coordinate suspension of 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 claims adjustment
Design utilization management programming edits, including quantity/dosing thresholds, to minimize drug wastage
Manage, develop, and train staff; monitor goals; conduct annual performance reviews; and administer staff salaries
Travel approximately 10–12 times per year within New Jersey to vendor audit sites

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 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 and/or clinical information
Ability to communicate policy and procedure to customers
Ability to work well within a team
Proven time management skills
Ability to manage multiple priorities and deliver timely and accurate work products
Ability to work in a production-focused environment
Sound judgment and strong problem-solving skills
Ability to ask probing questions and obtain thorough and relevant information
Ability to utilize a personal computer and applicable software
Strong negotiation skills

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Meaningful work that directly improves lives
Mission-driven organization that values expertise, collaboration, and growth