Mgr, Pharmacy Network Integrity

The user wants me to reformat a job posting into clean, well-structured semantic HTML. I need to follow specific rules: 1. Use

for section headings (About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule) 2. Use

• for lists of duties/requirements/benefits, and

  for prose 3. Do NOT repeat the job title as a heading 4. Do NOT put Job ID / requisition numbers as headings 5. Preserve ALL substantive information; do NOT invent or summarize away detail 6. Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions 7. Include a section ONLY when the posting has real, specific content for it — never emit a heading followed by filler/placeholder text 8. Never create Pay/Schedule/Benefits sections unless the posting actually states them 9. Prefer a few substantive sections over many thin ones 10. Output ONLY the HTML fragment — no /, no markdown code fences Let me analyze the job posting: - Company description: "Horizon Blue Cross Blue Shield of New Jersey empowers our members..." - this is company boilerplate, but it's substantive about the company. I should include it as a paragraph or maybe under an "About the Company" section? The rules say use h3 for section headings like "About the role". The company description could be a paragraph before sections. - "About The Role" section: This has a paragraph describing the role. I'll use

  About the Role

  and then

  for the prose. - "What You'll Do" section: This is a list of responsibilities. I'll use

  Responsibilities

  and
  • for each bullet. - "Education/Experience" and "What You Bring": This includes degree requirement, years of experience, licensing, knowledge, skills. I'll need to organize into sections: maybe "Requirements" for education/experience/licensing, "Knowledge" for knowledge requirements, "Skills" for skills and abilities. - "Additional Licensing, Certifications, Registrations": Active unrestricted NJ Pharmacist License Required. - "Knowledge": list of knowledge requirements. - "Skills And Abilities": list of skills. - "Travel": Hybrid Schedule - 1-2 days per week on-site, Approximately 10-12 trips per year within New Jersey to vendor sites for audits. This could be a "Schedule" section. - "Why Horizon?": This is benefits/culture description. Could be "Benefits" section. - "Salary Range": $109,600 - $149,625 with explanation. This is a "Pay" section. - "Disclaimer": This is legal boilerplate (EEO, accommodation, residency requirement). Should be removed per rules: "Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate". The residency requirement might be relevant? It says "Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware." That's a requirement. But it's in the disclaimer. Might be considered legal boilerplate. The rules say remove EEO/equal-opportunity boilerplate. The residency requirement is a job requirement. I'll include it maybe in Requirements? But it's in the disclaimer. I'll consider including it as a note. - Also "This job summary has been designed to indicate the general nature..." - that's boilerplate. I need to avoid duplicating lines. The "What You'll Do" list has some duplication with "About The Role" paragraph. The "About The Role" paragraph summarizes some duties. The "What You'll Do" list is more detailed. I'll keep both but ensure no duplication. Now, structure: 1. Company description: maybe a

    at the top, no heading. 2.

    About the Role

    with the paragraph. 3.

    Responsibilities

    with
    • for each bullet from "What You'll Do". Note: the list items are separated by periods in the text. I need to split them into separate list items. The text: "Design and revise on an ongoing basis all the necessary program elements and tools required to mitigate Pharmacy Fraud, Waste and Abuse.Leads all program efforts and collaboration with applicable regulatory agencies associated with all Pharmacy Fraud, Waste, and Abuse program and efforts, i.e. NJ Medicaid Fraud Division, Federal Bureau of Investigation, Medicaid Fraud Control Unit, NJ Division of Medical Assistance and Health Services in efforts to ensure that the Pharmacy Fraud, Waste and Abuse program satisfies all key metrics for the program as established by senior leadership.Responsible for ensuring that all program elements are in full compliance with all State, Federal and Division of Medical Assistance and Health Services (DMAHS) contractual and regulatory requirements on an ongoing basis.Develop and implement all necessary algorithms and programming required for staff to effectively identify potentially fraudulent pharmacy claims activity.Provide effective training to staff responsible for the review of all high dollar and seemingly aberrant Medicaid pharmacy claim payments for subsequent reconciliation and recovery.Educate and lead staff on the appropriate methodology and approach for the pharmacy desktop audit program, and subsequent reporting and presentation of program impact to Sr. leadership on an ongoing basis.Ongoing identification of necessary POS Rx system edits designed to mitigate future aberrant claims and unnecessary claims expenditures. Provide leadership, education and training to staff on methodology utilized for this purpose.Lead the clinical oversight and collaboration efforts with the pharmacy audit vendor and site selection for all on-site retail pharmacy audits.Design a process to be utilized to identify and coordinate the suspension of claim payments for all excluded and debarred providers. Provide leadership, education, and training to staff on logic utilized for this purpose.Accountability for review of pharmacy J and Q code payments made to physicians and hospitals to ensure reasonableness of quantities billed and amounts paid. Ongoing and timely reporting of aberrant claims identified to the Director of GP Operations to allow for any necessary claims adjustment.Responsible for designing all necessary utilization management programming edits i.e. Quantity/dosing thresholds in the claims payment system to ensure drug wastage is minimized.Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff." I'll split by sentences (periods) but careful: some sentences have internal periods (e.g., "i.e."). Better to split by the pattern of capital letter after period? The text is concatenated without spaces after periods. I'll manually separate each distinct responsibility. Let me list them: - Design and revise on an ongoing basis all the necessary program elements and tools required to mitigate Pharmacy Fraud, Waste and Abuse. - Leads all program efforts and collaboration with applicable regulatory agencies associated with all Pharmacy Fraud, Waste, and Abuse program and efforts, i.e. NJ Medicaid Fraud Division, Federal Bureau of Investigation, Medicaid Fraud Control Unit, NJ Division of Medical Assistance and Health Services in efforts to ensure that the Pharmacy Fraud, Waste and Abuse program satisfies all key metrics for the program as established by senior leadership. - Responsible for ensuring that all program elements are in full compliance with all State, Federal and Division of Medical Assistance and Health Services (DMAHS) contractual and regulatory requirements on an ongoing basis. - Develop and implement all necessary algorithms and programming required for staff to effectively identify potentially fraudulent pharmacy claims activity. - Provide effective training to staff responsible for the review of all high dollar and seemingly aberrant Medicaid pharmacy claim payments for subsequent reconciliation and recovery. - Educate and lead staff on the appropriate methodology and approach for the pharmacy desktop audit program, and subsequent reporting and presentation of program impact to Sr. leadership on an ongoing basis. - Ongoing identification of necessary POS Rx system edits designed to mitigate future aberrant claims and unnecessary claims expenditures. Provide leadership, education and training to staff on methodology utilized for this purpose. - Lead the clinical oversight and collaboration efforts with the pharmacy audit vendor and site selection for all on-site retail pharmacy audits. - Design a process to be utilized to identify and coordinate the suspension of claim payments for all excluded and debarred providers. Provide leadership, education, and training to staff on logic utilized for this purpose. - Accountability for review of pharmacy J and Q code payments made to physicians and hospitals to ensure reasonableness of quantities billed and amounts paid. Ongoing and timely reporting of aberrant claims identified to the Director of GP Operations to allow for any necessary claims adjustment. - Responsible for designing all necessary utilization management programming edits i.e. Quantity/dosing thresholds in the claims payment system to ensure drug wastage is minimized. - Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff. That's 12 items. 4.

      Requirements

      for education/experience/licensing. Could combine education, experience, licensing. - Bachelor degree is required in Pharmacy or Pharm D from an accredited college or university. - Requires a minimum of 5 years of recent practice as a Registered Pharmacist, preferably in New Jersey in a retail, PBM, managed care or auditing environment. - Requires a minimum of three (3) years prior pharmacy auditing experience. - Active unrestricted NJ Pharmacist License Required. 5.

      Knowledge

      for knowledge requirements: - Requires private and government third party prescription program operations. - Requires State of NJ Board of Pharmacy Regulations. - Requires state and federal Controlled Drugs and Substances regulations. - Requires Federal Pharmacy regulation including DESI and MAC policies. 6.

      Skills

      for skills and abilities: - Must be customer focused with effective ability to empathize. - Demonstrated professional and ethical business practices, adherence to company standards code of conduct and conflict of interest, and a commitment to personal and professional development. - Effective verbal and written communication skills including the ability to deliver highly technical and or clinical information to less technical and / or non-clinical individuals. - Ability to effectively communicate policy and procedure to customers in an effort to inform and educate. - Demonstrated ability to work well within a team. - Proven time management skills. - Ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. - Demonstrated ability to work in a production focused environment. - Proven ability to exercise sound judgment and strong problem solving skills. - Proven ability to ask probing questions and obtain thorough and relevant information. - Requires the ability to utilize a personal computer and applicable software. - Strong negotiation skills. 7.

      Schedule

      for travel/hybrid: - Hybrid schedule: 1–2 days per week on-site. - Approximately 10–12 trips per year within New Jersey to vendor sites for audits. 8.

      Benefits

      for "Why Horizon?" and benefits list: - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Also the "Why Horizon?" paragraph: "At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!" This is prose, could be a

      before the list. 9.

      Pay

      for salary range: - Salary range: $109,600 – $149,625 per year. - The compensation range is specific to the job level and takes into account factors such as education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.