Sr. Director, Pharmacy - Prior Authorization & Call Center

Senior Director, Pharmacy Prior Authorization And Call Center

The Blue Shield of California (BSC) Pharmacy team is passionate about making a meaningful impact by reimagining pharmacy care. Ensuring every member has safe, equitable access to sustainably affordable pharmacy benefits is at the heart of everything we do. The Senior Director, Pharmacy Prior Authorization and Call Center will report to the Senior Vice President of Pharmacy Services at BSC. In this role you will manage a team of over 200 employees and in collaboration with the Medical Director, be responsible for designing, executing, and optimizing prior authorization and call center processes to ensure clinically appropriate, cost effective, and compliant patient care. You will work cross functionally and partner with vendors as appropriate to optimize patient access while supporting affordability of medications covered under pharmacy and medical benefits for all lines of businesses.

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

In this role, you will:

• Lead and manage the prior authorization team to meet clinical, regulatory and business objectives of the prior authorization program
• Lead and manage the pharmacy call center team to support inbound and outbound provider calls to coordinate access to appropriate drug therapy for members
• Implement and maintain medication coverage policies for drugs in the pharmacy and medical benefits that promotes evidence-based coverage decisions
• Collaborate with analytics and business areas to drive evaluation of prior authorization program outcomes and performance, and identify opportunities to improve
• Develop and implement Prior Authorization vendor oversight program and process to ensure compliance with expected clinical and regulatory standards
• Collaborate cross-functionally with BSC Medical Directors, Appeals and Grievance and care management teams to share accountability for evidence-based decision-making, promote adherence to BSC coverage policies, facilitate care coordination and optimize customer experience
• Implement strategies and technology enhancements (e.g. automation, AI) to improve program effectiveness and operational efficiency
• Participate in regulatory or quality audits that involve the review of utilization management program
• Build a high performing team and drive leadership principles among managers, and foster a great workplace to do meaning work

Qualifications

In this role, you will need:

• A current active and unrestricted California Registered Pharmacist (RPh) license
• A Doctor of Pharmacy (PharmD) degree from an accredited school of pharmacy in the U.S.
• 12 years of prior experience in: a managed care health plan or pharmacy benefit management companies or other relevant settings; pharmacy prior authorization program and call center operations; developing and implementing strategic operational plans to optimize efficiency and cost outcomes
• 6 years of people management experience
• Prior experience in vendor management and oversight preferred
• Thorough knowledge regarding therapeutic use of drugs and available national guidelines preferred
• Knowledge of pharmacy benefits, formulary, network programs for drugs covered in pharmacy and medical benefits preferred
• Strong financial and business acumen with the ability to leverage performance data to drive operational improvements
• Excellent interpersonal, written & verbal communication skills
• Strategic and analytic thinking; problem-solving skills informed by data and evidence

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week. Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

About Us

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.