Senior Director, Prior Authorization & Clinical Care Operations

About Capital Rx 

Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi®, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.

Position Summary:
We are seeking a visionary and results-driven Director to lead and oversee Prior Authorization Operations, with responsibility for all lines of business (LOBs), including Commercial and Medicare, as well as the Clinical Call Center. This role will manage the end-to-end operations of Prior Authorization processes and ensure optimal efficiency, compliance, and performance across the department. Reporting to the Senior Director, the Director will set the strategic direction for the PA and Clinical care teams, drive cross-functional collaboration, and optimize operations to align with the organization’s broader business goals.

Position Responsibilities:

• Define and execute the strategic vision for Prior Authorization and Clinical Care Operations teams across all lines of business (Commercial, Medicare, Exchange, Medicaid, etc.) in alignment with overall company objectives.
• Lead the development and implementation of long-term goals to improve workflow and efficiency while maintaining high-quality standards.
• Lead and develop a large team of pharmacists, technicians, and support staff to deliver efficient and accurate Prior Authorization and Clinical Care operations.
• Champion the adaption of advanced automations to improve accuracy, efficiency, and decision making.
• Lead and manage client needs, requests, and meetings as it pertains to the Prior Authorization and Clinical Care functions including leading and actively participating in calls with clients, consultants, and other external stakeholders.
• Serve as a liaison with internal stakeholders, including other departments in Clinical Operations, to ensure transparency, collaboration, and effective communication regarding Prior authorization and Clinical Care operations and requirements.
• Ensure that Prior Authorization and Clinical Care processes comply with regulatory standards, including URAC, NCQA, and federal and state guidelines, managing risks associated with compliance, regulatory audits, and industry certifications.
• Support the development of Capital Rx’s formulary management platform
• Provide strategic direction and mentorship to PA leadership to foster a culture of collaboration, professional growth, accountability, and team success.
• Drive the development of KPIs and performance metrics for the PA department, ensuring that progress is measured against both departmental and organizational goals.
• Prepare and present executive-level reports, highlighting key performance trends, challenges, and recommendations for improvement.
• Key stakeholder and SME for Prior Authorization to the development team to implement advanced solutions that increase operational agility.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Required Qualifications:

• Active, unrestricted pharmacist license required
• Doctor of Pharmacy degree required
• 8+ years of experience in Prior Authorization or Utilization Management at a PBM, health plan, or healthcare provider organization
• 5+ years of leadership experience, including direct supervision in a complex, multi-functional environment
• Proven track record of leading large teams and managing complex prior authorization and clinical care operations
• Strong knowledge of pharmacy regulations, accreditation standards, and compliance requirements
• Client facing experience required
• Experience in overseeing multiple lines of business including Commercial, Exchange, and Medicare
• Experience in managing Clinical Call Center operations and integrating customer service teams.
• Proven ability to define and execute strategic operational plans for large-scale operations at a senior leadership level, translating organizational strategy into actionable department-level initiatives
• Strong financial acumen including the ability to manage unit cost
• Innovative problem-solver with a continuous improvement mindset
• Strong proficiency in data analysis and performance reporting, with the ability to leverage insights for decision-making
• Excellent communication skills, both written and verbal, with significant experience in presenting to executive leadership
• Proficiency in Microsoft Office Suite and familiarity with other advanced data and reporting tools (e.g., Tableau, Power BI, etc.)
• In-depth understanding of regulatory compliance and industry standards such as URAC, NCQA, and federal/state requirements
• Ability to work effectively in a fast-paced, evolving environment and manage complex, cross-functional teams

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.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.