Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. About the Role This position is accountable for supporting Pharmacy clinical management. The responsibilities include assisting in formulary management, medication therapy management, utilization management, research and collaboration with disease management and medical management. What You'll Do - Supports the pharmacy formulary management program, medication therapy management program, and related P&T committee activities. - Supports prior authorization program by handling prior authorization requests from Pharmacies and physicians through existing policies and procedures. - Interfaces with medical directors, and other areas for Pharmacy related initiatives - Supports the Utilization management program. - Responsible for member interface through comprehensive medication review for Medicare beneficiaries. - Assist in managing and training Pharmacy techs for Medication therapy management. - Responsible for Medicare beneficiaries pharmacy management program, understand the mandates and follow the guidelines. - Supports clinical programs both internally and externally. - Assists with the internal drug information services. - On call responsibility as required. - Reviews and analyze reports on utilization management, and evaluates business needs for data analysis. - Support the Drug Utilization review program. - Manage and update formulary communications. - Coordinates projects with activities performed by other clinical Pharmacists for the residents and students. - Participates in the Pharmacy Case Management Program. - Supports the pharmacy lock-in program including profile review and presentation. - Maintains and reports relevant drug pipeline/patent loss detail to medical team. - Supports the timely review of Pharmacy appeals. - Assists in the creation of member and provider newsletters. What You Bring Education/Experience: - Requires a bachelor's of science degree in pharmacy from an accredited college or university. - Prefers a Pharm D from an accredited college or university. - Prefers up to one to two year experience in managed care. - Requires retail, or other pharmacy experience. Additional licensing, certifications, registrations: - Active Unrestricted NJ Pharmacy License Required Knowledge: - Requires working knowledge of pharmaceutical and managed care industries. - Requires knowledge of a spreadsheet software package. - Requires knowledge of a database software package. - Requires knowledge of Clinical therapeutics and basic therapy and guidelines and recommendations. - Requires knowledge of Internet clinical information databases. Skills and Abilities: - Strong negotiation skills with the demonstrated sales ability to convert prospect to client in addition to demonstrated persuasive skills with carriers - Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals. - Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development. - Proven time management skills are necessary. Must demonstrate the 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. - Must be client service focused with effective ability to empathize. - Needs to demonstrate willingness to cross-train, and be cross-trained, in other roles/duties. - Must be detail oriented with strong organizational and data processing skills. Proven ability to follow detailed instructions is essential, along with proven problem solving skills. - Proven analytical, research and problem solving skills a must. - Must demonstrate the ability to learn quickly and apply learning to new situations. Must exhibit flexibility to change as appropriate. - Must demonstrate the ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. - Exhibits an energetic, inquisitive, positive approach to problem solving. - Demonstrated ability to make decisions with little need for direction and to function effectively as a team-oriented, self-starter working across cross-functional lines. - Experience in successfully leading cross-functional teams to achieve improvements. - Must have a demonstrated ability to expand new business, grow client relationships and obtain client referrals. - Must have strong entrepreneurial business development, negotiation, relationship building, and networking skills. - Demonstrated management experience with a focus on customer service, goal setting, and coaching. Exhibits proven leadership, delegation and project management skills. - Proven ability to influence without authority. - Must be able to share own professional insights, expertise, and knowledge to develop critical thinking across the business. - Proven leadership skills in direct and matrix reporting structures - Collaborates on planning and executing the sales strategy, involvement in presentations, and participation in client meetings as appropriate. Why Horizon? 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! Salary Range: $97,800 - $133,455 ​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: 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. Horizon also provides a comprehensive compensation and benefits package which includes: - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

• Monitor and support clinic function during daytime hours, proactively identifying and communicating operational constraints • Identify patient treatment gaps and collaborate with clinical leadership to help reassign resources as needed • Track operational metrics, workflows, and service levels, escalating issues or delays promptly to leadership • Contribute to process improvement initiatives and ensure clinic operations align with compliance standards and internal policies • Partner with the clinical and operations leadership team to ensure clinician coverage aligns with volume and care needs • Triage and respond to real-time staffing issues, including call-outs and unexpected visit surges • Manage and maintain clinical schedules across clinician types, ensuring adequate coverage based on forecasted volume and business needs • Adjust schedules as needed to accommodate time off, unplanned absences, or changes in patient volume • Conduct regular schedule reviews to ensure accuracy and balance • Coordinate with provider operations to ensure clinicians are only scheduled in licensed and compliant states • Identify operational bottlenecks; collaborate with clinical, product, and support teams to improve workflows • Monitor and report issues with key performance indicators related to staffing, patient wait times, and operational SLAs in day-to-day work • Support compliance with internal policies and regulatory requirements • Work closely with provider operations, medical leadership, and support staff to ensure alignment across teams • Actively participate in ongoing process improvement initiatives and special projects • Other duties may be assigned as determined by clinic need • Rotating weekends may be required

Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions: - Complete prospective, concurrent and retrospective review of Behavioral Health services - Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care - Engage with medical director when additional clinical expertise if needed - Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards - Identify and refer quality issues to Quality Improvement - Identify and refer appropriate members for Care Management - Provide guidance to non-clinical staff - Provide guidance and support to LPN staff - Attend medical advisement and State Hearing meetings, as requested - Assist Team Leader with special projects or research, as requested - Perform any other job related duties as requested. Education and Experience: - Associates of Science (A.S) in Nursing required or - Bachelor of Science (B.S) in Social Work required - Three (3) years clinical experience required - Utilization Management/Utilization Review experience preferred - Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: - Proficient data entry skills and ability to navigate clinical platforms successfully - Working knowledge of Microsoft Outlook, Word, and Excel - Effective oral and written communication skills - Ability to work independently and within a team environment - Attention to detail - Proper grammar usage and phone etiquette - Time management and prioritization skills - Customer service oriented - Decision making/problem solving skills - Strong organizational skills - Change resiliency Licensure and Certification: - Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required - MCG Certification is required or must be obtained within six (6) months of hire required Working Conditions: - General office environment; may be required to sit or stand for extended periods of time - Travel is not typically required Compensation Range: $62,700.00 - $100,400.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Optum at Home Pharmacy Stars Team provides a variety of services including United HealthCare at Home (UAH) strategic Medication Adherence outreach initiatives, Care of Older Adults (COA) medication reviews/health assessments, SUPD/SPC provider consultations as well as Poly ACH and COB outreach. Additionally, the team does various outreaches during the year targeted at improving stars measures such as BP and DM consultations with members. The team also supports APC providers via a clinical consultation service. All services are provided by a team of Clinical Pharmacists, with the support of Pharmacy Technicians, and Clinical Quality RN’s that engage with plan members and their healthcare providers in a telephonic environment. The Clinical Pharmacist will report to the Clinical Team Manager (CTM) within the Optum Enterprise Care Services department. The primary responsibility of the Clinical Pharmacist will be to perform clinical consults via telephone with members served by the UAH program and providing services such as optimizing medication therapy, adherence counseling, drug interaction screening, and disease state counseling for diabetes, hypertension, hypercholesterolemia, and much more. The Clinical Pharmacist will be an integral part of a team of Clinicians of varying disciplines and will be expected to meet or exceed established productivity and quality metrics as well as staying engaged throughout the process, helping the department reach yearly goals together as a team. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Conduct medication consults with members telephonically that meet/exceed both internal and external quality metrics for OAH Med Adherence Stars , COA MR & FN, SUPD/SPC, & Poly Ach/COB - Identify and address member specific medication adherence barriers. Collaborate with patient’s providers and/or pharmacy to overcome barriers to improve STARs rating - Implementing a health literate member-centric approach within all clinical consults performed - Participating and engaging on a team of other clinicians both in person and virtually - Supports patients in their initiation and maintenance of new therapy, providing education, optimizing utilization, and establishing adherence - Meet or exceed established production metrics on a weekly and monthly basis - Meet or exceed established quality and health literacy metrics on a weekly and monthly basis - Meet or exceed established adherence attributable fill rate - Conducting various additional campaigns throughout the year based on the needs of the business, which will be assigned by the CTM - Provide support to Advanced Practice Clinicians (APC’s) in the field via telephonic clinical consultation - Actively participating in coaching sessions to both improve and maintain clinical interaction skills and overall performance You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: - Licensed pharmacist requires graduating from a college or school of pharmacy accredited by the Accreditation Council for Pharmacy Education (ACPE), such as a Doctor of Pharmacy Program (PharmD) program and passing the North American Pharmacist Licensure Exam, or NAPLEX - Current unrestricted and active pharmacist license in the state in which they are practicing - 1+ years of Clinical Pharmacy Practice experience - 1+ years of experience with Microsoft Word, Excel, Outlook, PowerPoint - Ability to type and talk at the same time while navigating through multiple screens - Have a designated secure and private workspace free of distraction and protecting HIPAA confidentiality of our members. No childcare permitted during working hours - Access to install secure high-speed internet via cable/DSL in home as well as connect directly into internet - via hard wire (either directly to modem or router) - Ability to keep all company sensitive documents secure (if applicable) Preferred Qualifications: - MBA/MPH Degree - Post Graduate Training (Pharmacy Residency and/or Fellowship) - Active, unrestricted pharmacy license in one of the states considered as Restricted (AL, ID, KY, LA, MD, OR, TN, VT) - Certified Geriatric Pharmacist - Board certification by the Board of Pharmacy Specialties (BPS) - 1+ years of call center experience - Experience with Medication Therapy Management (MTM) & Comprehensive Medication Reviews - Experience with Medicare STARs & HEDIS Measures - Proven written and verbal communication skills to interact with patients and clinic staff - Proven solid interpersonal skills - Proven excellent written and verbal communication and relationship building skills - Proven ability to work independently, as well as a member of a team - Bilingual in Spanish, Mandarin, Cantonese, Korean, Russian, or Vietnamese *All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 to $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.