Position Summary:

• Acts as a subject matter expert on Medicare prior authorization and appeals operations that are compliant to CMS and other regulatory standards. Responsible for the oversight of prior authorization processes, prior authorization pharmacists, staff schedules, skilling, performance, and managing compliance risks.

Position Responsibilities:

• Responsible for supervision of Medicare pharmacists with expanded responsibility for select administrative PA functions
• Oversight of Medicare job aids, work instructions, and letter language templates
• Maintain knowledge of CMS regulations and guidelines that impact CDAG and ODAG case reviews and processes
• Work in conjunction with the Medicare Manager in analyzing data and provide recommendations for prior authorization staffing, workflow, and system enhancements
• Collaborate with the Appeals Supervisor to ensure appropriate staffing and develop workflow processes
• Support on-going training of current staff and onboarding new Medicare pharmacists
• Support, coach and manage the Medicare pharmacists and provide information (verbally, or through email, job aids or policies and procedures) to the team as needed
• Provide performance feedback to team members through quality assurance, coaching and performance reviews

• Create and manage team schedules to ensure flexibility and adequate coverage for the workday
• Prior authorization queue management, supervise the daily operations of the queue, monitor for compliance risk and update skilling based on business needs
• Work with business and clinical partners as needed
• Investigate/resolve escalated issues or problems from clients and providers
• Perform day to day clinical pharmacy functions as needed including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls
• Handle inbound phone inquiries regarding Medicare prior authorization and/or appeal requests
• Ability to work in a fast-paced environment with shifting priorities

• Work in conjunction with the Medicare Manager on other responsibilities, projects, implementations, and initiatives as needed

Minimum Qualifications:

• Active, unrestricted pharmacist license
• Bachelor's or Doctor of Pharmacy Degree with 2+ years of pharmacy practice experience
• 2 years of experience in prior authorization in a Pharmacy Benefit Management (PBM) or health plan setting
• Strong understanding of pharmacy benefit management processes including claims processing, formulary management, prior authorizations, 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, provide support, and foster a collaborative work environment
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven call center environment
• Strong written communication and oral presentation skills
• Self-motivated and detail-oriented problem solver
• Ability to handle multiple competing priorities in a dynamic environment and collaborate in a team
• Have a designated workspace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations
• Have the following internet connectivity: DSL, cable modem or fiber with a wired connection to device (wi-fi not allowed). Internet speed of one gigabyte (940bps) is required
• Working knowledge of MS Office Suite (Word, Excel, PowerPoint, Outlook)
• Ability to work 11:00 am – 8:00 pm EST Monday through Friday as well as on-call rotation for weekends, holidays, and after-hours.

Preferred Qualifications:

• 1+ year of experience reviewing Part D coverage determinations & appeals or Part B organizational determinations & appeals
• 1+ year of applying CMS regulations to Medicare prior authorization and appeals processes
• 1+ year of leadership experience in a remote environment