Position Summary:

Acts as subject matter expert on prior authorization and appeals operations that are compliant to federal, state, and other regulatory standards for multiple lines of business including Commercial, Commercial Exchange, FEHB, Medicare Part B&D, and Medicaid, and responsible for the oversight of prior authorization processes of prior authorization pharmacists, staff schedules, skilling, performance and managing compliance risks.

Position Responsibilities:

• Responsible for supervision of a group of appeal pharmacists and technicians with expanded responsibility for select administrative PA functions.
• Oversight of appeal job aids and clinical denial language.
• Work in conjunction with Manager in analyzing available data and provide prior authorization staffing, workflow and system enhancement recommendations.
• Support on-going training of current staff and onboarding new Appeals pharmacists.
• Investigate/resolve escalated issues or problems from clients and providers.
• Works with appeal manager on other responsibilities, projects, implementations and initiatives as needed.
• Collaborate with Medicare supervisor to ensure appropriate staffing and develop workflow processes.
• Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
• Make clinical decisions in accordance with medical necessity and contract criteria
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers
• Communicate effectively with providers and members to promote positive health outcomes
• Handle inbound phone inquiries regarding prior authorization and or appeal requests.
• Review pharmacy claims data for proactive outreach and intervention
• Identify and monitor inappropriate trends in care to improve quality and cost effectiveness
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements
• Participates in the quality improvement committee and supports quality improvement projects as required by URAC (5-10% of time)
• Work with business and clinical partners as needed
• Ability to work in a fast-paced environment with shifting priorities
• Prior authorization queue management, supervise the daily operation of the queue, monitor for compliance risk and update skilling based on business needs

Minimum Qualifications:

• A Doctor of Pharmacy (Pharm.D.) degree or Bachelor of Pharmacy degree from an accredited pharmacy program.
• An active unrestrictive pharmacist license.
• 2 years of experience as a clinical pharmacist in a Pharmacy Benefit Management (PBM) setting.
• 1+ year of experience working with Commercial and/or Medicare appeals.
• Strong understanding of pharmacy benefit management processes, including claims processing, formulary management, prior authorization, and appeals.
• Excellent analytical skills, showcasing an ability to analyze complex pharmacy claims and medical records, identify issues, and propose appropriate solutions.
• Strong leadership skills, including the ability to motivate and manage a team, provide guidance, and support, and foster a collaborative work environment.
• Proficiency in using Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
• Ability to work any shift EST Monday through Friday as well as on-call rotation for weekends, holidays, and after-hours.

Preferred Qualifications:

• 1+ year of leadership experience in a remote environment.

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.