POSITION SUMMARYThe Manager, Prior Authorization is responsible for the strategic, clinical, and operational leadership of the Prior Authorization (PA) department. This position oversees prior authorization operations across all lines of business, ensuring timely, accurate, and clinically appropriate review and processing of prior authorization requests, appeals, and coverage determinations. The Manager serves as the department subject matter expert for all prior authorization and FillNBill.
RESPONSIBILITIES- Provide leadership, direction, and oversight for all Prior Authorization operations.
- Directly supervise Prior Authorization Supervisors, Prior Authorization Pharmacists/Nurses, and Prior Authorization Specialists, as applicable.
- Interview, hire, train, coach, develop, and evaluate department personnel.
- Establish departmental goals, productivity standards, quality expectations, and key performance indicators (KPIs).
- Monitor department workload, staffing levels, and resource allocation to ensure service level expectations are met.
- Conduct performance evaluations and provide ongoing coaching and professional development for team members.
- Develop and maintain standard operating procedures, workflows, and training programs related to prior authorization operations.
- Identify operational barriers and implement process improvements to enhance efficiency, quality, and customer satisfaction.
- Monitor department performance metrics and implement corrective actions when goals are not achieved.
- Lead performance improvement initiatives and monitor outcomes to ensure continuous operational excellence.
QUALIFICATIONS- Requires a bachelor's degree and/or an advanced degree in pharmacy with at least 3 years of experience and is licensed to practice in state.
- Prior experience with performing Prior Authorizations within the pharmacy, pharmacy benefit insurance or PBM field. One year of clinical experience is preferred. Familiar with a variety of concepts, practices, and procedures with a focus on mail-order pharmacy.
- Knowledge of PBM industry, formulary management, pharmacy claims and managed care principles and practices desired. Exceptional clinical skills and ability to apply sound clinical judgment to various situations is needed.
- 340B knowledge is a plus.
- At least one year of Medical Writing experience preferred.
