Director, Pharmacy Coverage Reviews

Worker Type: Employee
Company: BlueCross BlueShield of Tennessee, Inc.

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.

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

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

Skills

• 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