New

Sr Program Manager Pharmacy

Blue Cross Blue Shield Association
vision insurance, 401(k)
United States, D.C., Washington
1310 G Street Northwest (Show on map)
May 14, 2025
The hiring range for this role is: $93,800.00 - $131,300.00 This is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range and this hiring range may also be modified in the future. A candidate's position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs.This job is also eligible for annual bonus incentive pay. We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits to eligible employees. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. Manages the day-to-day Pharmacy operations and/or staff. Directs the Pharmacy Benefit Manager (PBM) account relationship and daily operations, providing operational oversight and leadership for the Federal Employee Program (FEP). Ensures vendor performance, member benefit implementation and compliance with FEP & CMS policies and vendor contracts. Supports operational excellence, customer satisfaction and ensures utilization of incentivized benefits to result in cost efficiencies and program savings. If managing people, she/he will direct staff to lead multiple programs, projects, and associated deliverables, of significant complexity and/or impact, related to FEP's prescription drug benefits. Provides guidance and oversight over all interactions between FEP and the PBM for Pharmacy Programs. Supports and functions as the Pharmacy Programs strategic and operational resource and as the Subject Matter Expert (SME) for interactions with key stakeholders, including various BCBSA cross-functional teams, FEP Operations Center, local Plans, OPM, Veteran Affairs Administration, and the PBM vendors.Oversees Digital Member Experience to ensure scheduled enhancements and maintenance of the internal and vendor program sites are consistent to minimize disruption and optimize member and client experience. Guides development of strategy and timelines for enhanced member and Plan communications to meet fixed deadlines dictated by OPM. Supports and directs development of multifaceted communications for members and Plans during Open Season - direct mailing, targeted mailing, benefit summary book and pamphlets. Ensures program is compliant through the validation of PBM audits, evaluation of CMS compliance and adherence to protocol and standards and invoice process review.Directs and oversees the Secure File Transport Protocols (SFTP) sites for use by multiple vendors to ensure adherence to HIPAA privacy and security protocols. Evaluates vendor performance and ensures compliance with contractual standards and applicable federal regulations. Develops and maintains contract compliance monitoring tools and dashboards. Evaluates operational processes and assesses the impact on the FEP program and member services relative to FEP performance goals. Investigates nonperformance and directs vendor efforts to ensure corrective actions are implemented timely. Participates in the negotiation of contracts and amendments; develops proposals and counter proposals. Undertakes a leadership role among staff to ensure appropriate delivery of member benefits consistent with FEP policies. Reviews and understands FEP Operations Center (FEPOC) claim processing protocols for prescription drug claims. Serves as liaison between FEPOC and PBM in resolving claim processing issues, explaining and prioritizing enhancements that impact members. Provides significant contribution to multiple aspects of the RFP competitive bidding and contracting process for PBM services, including technical proposal evaluation and scoring for competency, site visits and participation in contract negotiations. Leads and executes multiple cross-functional projects to maintain and enhance customer satisfaction with FEP Pharmacy Programs. Ensures timely resolution of customer inquiries (members, Plans, OPM, Congressional, Internal FEP Staff). Reviews PBM standard operating procedures (SOP) for Call Center management, Front-end and Back-end pharmacy processes, as well as training materials and curriculum for customer service representatives to ensure optimal service is provided to FEP members. Monitors Pharmacy network requirements to ensure PBM has contracted with sufficient pharmacies to meet FEP standards for member access. Leads the design, development and distribution of multiple communication pieces necessary to inform members, Plans and OPM of the structure of the pharmacy benefit. Responsible for directing vendor maintenance and updates to fepblue.org and vendor websites. Serves as subject matter expert for the review and update of the Pharmacy Programs policies detailed in the Administrative and Benefit Policy Manuals and the Service Benefit Plan brochures. Leads benefit design and implementation for pharmacy programs: including benefit negations with OPM, internal strategy meetings, cross-functional team meetings, functional specification documentation, implementation and testing with PBMs and FEPOC, benefit clarification discussions, and updating all policies and website information to incorporate the new benefits. Ensures timely and accurate receipt and review of all contractual reports - operational, financial, and clinical. Develops report summaries and dashboards that highlight critical performance metrics for Sr. Management review. Provides oversight for the design, development, and distribution of multiple communication pieces necessary to inform members and Plans of the structure of the Medicare part D pharmacy benefit. Supports vendor maintenance and updates to fepblue.org and vendor websites. Supports and functions as a subject matter expert for ensuring update of the Pharmacy Programs policies detailed in the Administrative and Benefit Policy Manuals, the Service Benefit Plan brochures are accurate and in compliance with FEP Program and CMS guidelines and standards. Coordinates and supports audits of Pharmacy Programs. Serves as subject matter expert for Pharmacy Programs providing assistance throughout the audit review - pre audit planning, resolution of findings and directs and monitors corrective actions. In conjunction with the Director of Pharmacy Compliance, monitors twice per month claim payment to PBM reconciling any differences between amounts invoiced and amounts approved to pay. Reviews and authorizes payment for monthly administrative fees. Pharmacy Program providing assistance throughout the audit review - pre audit planning, resolution of findings, and arrange corrective actions. Review and authorize payment for monthly administrative fees. Monitor twice per month claim payment to PBM reconcile any difference between amount invoiced and amount approved to pay. Scans business environment to develop proactive and strategic approaches to address program needs related to pharmacy benefit design. Partners with internal business units to develop sound business strategy. Evaluates health care legislation and business trends to maintain awareness of recent developments that have an impact on pharmacy programs. Utilizes information to recommend business strategy for potential implementation. Leads or participates on project teams as required by business strategy decisions and requested by FEP management. Education Bachelors Degree Masters Degree Bachelor's Degree in Pharmacy, Business, Accounting, Management or Health Services, or the equivalent years experience Pharmacy or Master's Degree in health services degree or equivalent experience Certifications Technical proficiency with information technologies (e.g. Microsoft software applications) Experience Minimum 7 years business experience within a business environment Minimum of 5 years' experience within a national health care and managed pharmacy delivery system Progressive experience in large account management and/or project management Prior project/program leadership experience that demonstrates the ability to set priorities and meet objectives for several complex projects involving multiple stakeholders Skills Ability to manage stakeholders and reconcile and integrate competing interests Ability to utilize/leverage knowledge of BCBSA stakeholders to develop and link long-term outcomes and action plans predicting associated results Ability to quickly attain knowledge of Association and division operations Ability to seek out and incorporate perspectives from other functional areas and develop alternative approaches to meet defined objectives Demonstrated analytical and organizational skills Ability to build consensus for business results in a decentralized decision-making structure Ability to build organized strategies related to department/divisional goals Interpersonal skills with the ability to work with all levels of the Association, Plans, government and vendors Ability to work individual or within a team with a variety of individuals performing many different functions with varying styles to accomplish goals Ability to build organized strategies related to department/divisional goals Knowledge of financial accounting, controls, auditing, quality assurance and contract administration People Management Varies #LI-Hybrid