Job Description

Job Responsibilities

• Direct day-to-day operations for prior authorization and appeals programs, ensuring efficient, compliant, and member-focused service delivery.
• Maintain and enforce clinical coverage policies, ensuring adherence to regulatory and accreditation standards (URAC, NCQA, CMS).
• Lead and mentor managers and staff, setting clear performance expectations and fostering continuous improvement in service quality and turnaround times.
• Monitor utilization trends, turnaround metrics, and appeal outcomes to identify improvement opportunities and support affordability initiatives.
• Partner with clinical strategy, pharmacy benefit management, and compliance teams to align coverage review operations with enterprise goals.
• Ensure documentation and review activities meet internal and external audit standards and support enterprise compliance efforts.
• Drive enhancements in coverage review processes through technology adoption, workflow optimization, and best practice integration.

Job Qualifications

Education

• Doctor of Pharmacy Degree (PharmD) required

Experience

• Minimum 8 years Clinical experience required
• Minimum 6 years Practical experience in a managed care environment
• Minimum 4 years of supervisory/leadership responsibilities required

Skills/Certifications

• Ability to lead coverage review operations and ensure compliance
• Expertise in policy implementation and regulatory standards
• Skill in data analysis for utilization trends and performance metrics
• Strength in cross-functional collaboration for operational alignment
• Leadership in driving process improvements and team development

License

• Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy

Number of Openings Available

1

Worker Type:

Employee

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.