Job Overview
Location
Remote flexibility for candidates in FL, IA, KS, MN, MO, NE, ND, or TX
Job Type
Full-time
Category
Data Science
Date Posted
June 3, 2026
Full Job Description
đź“‹ Description
- • Serve as the clinical expert on pharmacy-related utilization management (UM) programs in collaboration with the Director of Pharmacy and other staff pharmacists.
- • Develop, maintain, and update clinical criteria for UM programs, including Prime standard and BCBSNE-specific versions, ensuring alignment with regulatory and accreditation standards.
- • Design and document clinical workflow processes for UM reviews, including physician fax forms and alternative communication methods for clinical decision support.
- • Utilize predictive modeling tools to identify high-risk members with specific disease states and implement targeted clinical interventions.
- • Provide clinical oversight and review of first-level utilization management decisions, ensuring accuracy and compliance with clinical guidelines.
- • Perform complex research and analysis to recommend changes to UM programs and plan design based on claims data, outcomes, and industry best practices.
- • Support pharmacy technicians and other staff with clinical guidance during UM reviews, ensuring timely and appropriate clinical decision-making.
- • Use reporting tools to analyze medical and pharmacy claims data, identifying inefficiencies and developing solutions to improve review turnaround times and operational efficiency.
- • Develop and implement Decision Tree review processes for complex or non-standard UM cases to standardize clinical evaluations.
- • Maintain URAC accreditation by ensuring all clinical review activities comply with accreditation standards and state/federal regulations governing drug utilization review.
- • Ensure clinical pharmacists operate within their state licensure scope and do not conduct peer clinical reviews if prohibited by state law or if specifically requested by the reviewing party.
- • Monitor and report on quality assurance metrics, including turnaround times for urgent and non-urgent reviews, and conduct quantitative assessments of UM program performance.
- • Provide clinical direction and support for Medicare Advantage programs, including participation in outreach initiatives, provider education, and stakeholder presentations.
- • Deliver clinical presentations to internal teams, external providers, provider offices, and other customers to communicate program changes, clinical rationale, and care management strategies.
- • Collaborate cross-functionally to ensure pharmacy-related clinical programs are integrated with broader health plan objectives and member care initiatives.
- • Stay current with evolving pharmacy regulations, clinical guidelines, and managed care trends to inform program improvements and compliance efforts.
🎯 Requirements
- • Doctor of Pharmacy (Pharm.D.) from an accredited U.S. College of Pharmacy
- • Active, current, and unrestricted license to practice pharmacy in Nebraska
- • Must reside in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, or Texas
🏖️ Benefits
- • Remote flexibility with hybrid options available for candidates in FL, IA, KS, MN, MO, NE, ND, or TX
- • Opportunity to work for a mission-driven organization focused on member and community health
- • Collaborative culture with support for professional growth and meaningful impact
- • Exposure to Medicare Advantage programs and managed care pharmacy operations
Skills & Technologies
About Nebraska Blue Cross and Blue Shield
Nebraska Blue Cross and Blue Shield is a member-owned nonprofit health insurer headquartered in Omaha, providing medical, dental, vision, pharmacy, and supplemental coverage to individuals, families, and employers statewide. Founded in 1939, the company administers self-funded plans, Medicare Advantage, and Medicaid products, operating a statewide provider network of hospitals, physicians, and specialists. It also offers health-management programs, wellness incentives, and digital tools to improve care quality and affordability for more than 750,000 members.
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