**Job 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\. **Job 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 _Skills/Certifications_ + 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 _License_ + Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy **Number of Openings Available** 1 **Worker Type:** Employee **Company:** BCBST BlueCross BlueShield of Tennessee, Inc\. **Applying for this job indicates your acknowledgement and understanding of the following statements:** BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law\. Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page: BCBST's EEO Policies/Notices \(https://www\.bcbst\.com/docs/equal\-employment\-opportunity\.pdf\) **BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity\. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via\-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered\. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means\.** As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health since 1945\. More than that, we're your neighbors and friends - fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow\. At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members\. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability\. We're also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously\. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST\. We foster a culture where innovation is encouraged\. That includes using AI enabled tools responsibly to support everyday work - guided by proven workflows, templates, and policies\. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members\. BCBST is a remote\-first organization with many employees working primarily from their homes\. Each position within the company is classified as either fully remote, partially remote, or office based\. BCBST hires employees for remote positions from across the U\.S\. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York\. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense\.If the position requires the individual to reside in Chattanooga, TN, they may