Hi, we're Oscar. We're hiring a Clinical Pharmacist to join our Pharmacy team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family. About the role: This role serves as a reviewer of prior authorizations. You will report into the Clinical Pharmacist Supervisor. Work Location: This is a remote position, open to candidates who reside in: Alabama; Arizona; Arkansas; Colorado; Connecticut; District of Columbia; Florida; Georgia; Idaho; Illinois; Indiana; Iowa; Kansas; Kentucky; Maine; Maryland; Massachusetts; Michigan; Minnesota; Missouri; Nevada; New Hampshire; New Jersey; New Mexico; North Carolina; Ohio; Oregon; Pennsylvania; Rhode Island; South Carolina; Tennessee; Texas; Utah; Vermont; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $111,780 - $146,711 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program, and annual performance bonuses. Responsibilities: - Review and render decisions on authorizations and appeals for specialty, non-specialty, and physician administered drugs - Conduct peer-to-peer calls with prescribers to discuss the clinical rationale of adverse determinations - Participate in clinical quality audits and inter-rater reliability testing - Provide internal team support for escalations and questions - Apply clinical expertise to ensure appropriate and safe use of pharmaceuticals by members and providers. - Compliance with all applicable laws and regulations - Other duties as assigned Requirements: - 3+ years of experience as a licensed pharmacist - Active, unrestricted pharmacist license - Doctor of Pharmacy Degree - Willingness to obtain licensure/training with new states, as needed Bonus points: - 3+ years of experience performing clinical review in a managed care setting and experience writing clinical criteria - Strong clinical skills and experience applying clinical criteria in clinical review setting - Board Certification (i.e. BCPS, BCOP) - Residency training - Experience practicing pharmacy in a clinical setting (i.e. retail, hospital, specialty, etc.) This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants’ personal information as well as applicants’ rights over their personal information, please see our Privacy Policy.

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