Director of Prior Authorization

February 14

🐎 Kentucky – Remote

Although this job is listed in Kentucky, this company may be open to hiring remote in other states.

⏰ Full Time

🔴 Lead

👔 Director

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AffirmedRx, a Public Benefit Corporation

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AffirmedRx is a Public Benefit Corporation dedicated to transforming the pharmacy benefit management (PBM) industry. Focused on transparency, patient-centric care, and innovative solutions, AffirmedRx aims to overcome the complexities and opacity that traditionally plague the PBM sector. By empowering individuals and organizations, the company provides clarity and unwavering support in navigating pharmacy benefits. AffirmedRx stands for integrity and partnership, striving to offer a healthier and more informed pharmacy benefits experience while boldly tackling the rising costs of healthcare and pharmaceuticals.

PBM • Pharmacy Benefit Management • Healthcare Analytics • Healthcare • Pharmaceuticals

11 - 50 employees

⚕️ Healthcare Insurance

📋 Description

• The Director of Prior Authorization will lead and oversee the development, implementation, and management of our Prior Authorization (PA) operations. • This role will be responsible for building and managing a high-performing PA team, establishing efficient processes and procedures, and ensuring compliance with regulatory and accreditation standards. • The Director will work closely with internal teams and external stakeholders to support seamless PA operations, maintain accreditation requirements, and drive exceptional client and member outcomes. • Lead and develop a high-performing Prior Authorization (PA) team, including hiring, onboarding, training, and managing performance. • Manage supervisors and scale the team to support future growth, ensuring efficient resource allocation through effective staffing models. • Oversee PA operations by monitoring production and quality metrics to drive performance and operational excellence. • Develop and optimize PA processes and procedures to ensure operational excellence, scalability, and seamless integration with client systems. • Collaborate with internal teams, such as formulary management, to implement changes, maintain accurate denial language, and support process improvements. • Act as a clinical expert on prior authorization reviews and evaluations according to criteria and plan design. • Ensure accuracy of clinical guidance support provided to members, prescribers, and internal teams related to prior authorizations and clinical alternatives. • Review and evaluate clinical literature to support decision-making and recommendations to providers. • Manage client escalations, providing timely solutions to maintain satisfaction and trust while driving continuous process improvements. • Lead strategic initiatives, including technology migrations, electronic PA integration, and workflow enhancements, to improve PA operations and client outcomes. • Ensure compliance with URAC and NCQA standards, staying current with industry regulations and supporting audits as needed.

🎯 Requirements

• Bachelor's degree in Pharmacy • Advanced degree (PharmD, MSN, MPH, MBA) preferred • 10+ years of experience in prior authorization operations, clinical services or related roles, with at least 5 years in a leadership position • 3+ years of experience in pharmacy or pharmacy benefit management (PBM) preferred • Deep understanding of PA processes, staffing models, and clinical workflows • Knowledge of regulatory and accreditation requirements, particularly URAC and NCQA standards • Excellent analytical, organizational, and problem-solving skills • Ability to work collaboratively with cross-functional teams • Willingness and ability to travel (10%-20%)

🏖️ Benefits

• Competitive compensation, including health, dental, vision and other benefits