Associate Director, Prior Authorization Operations

Position Summary:

We are seeking a strategic and results-driven Associate 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 operations of Prior Authorization processes and ensure optimal efficiency, compliance, and performance across the department. Reporting to the Senior Director, the Associate Director will drive cross-functional collaboration and optimize operations to align with the organization’s broader business goals.

Position Responsibilities:

• Provide strategic direction and mentorship to PA and Clinical Care leadership to foster a culture of collaboration, professional growth, accountability, and team success.
• Develop, implement, and uphold policies, procedures, and best practices to ensure the prior authorization processes are efficient, compliant, and aligned with organizational goals.
• Define and execute long-term goals to improve workflow and efficiency while maintaining high-quality standards.
• Lead or actively participate in cross-departmental initiatives to enhance overall business operations focusing on optimizing the integration and performance of Prior Authorization processes within the broader organizational structure.
• Ensure that Prior Authorization processes comply with regulatory standards, including URAC, NCQA, and federal and state guidelines, managing risks associated with compliance, regulatory audits, and industry certifications.
• Drive the development of KPIs and performance metrics for the PA department, ensuring that progress is measured against both departmental and organizational goals.
• Generate and present comprehensive reports on PA metrics, operational performance, and process improvements to senior leadership and other stakeholders, providing actionable insights and recommendations.
• Support the Senior Director, Prior Authorization in various strategic projects, initiatives, and operational tasks to continuously improve the PA function.

Required Qualifications:

• Active, unrestricted pharmacist license required
• Doctor of Pharmacy degree required
• 6+ years of experience in Prior Authorization or Utilization Management at a PBM, health plan, or healthcare provider organization
• 4+ years of leadership experience, including direct supervision in a complex, multi-functional environment
• Experience in overseeing multiple lines of business including Commercial, Exchange, and Medicare
• 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.)
• Ability to work effectively in a fast-paced, evolving environment and manage complex, cross-functional teams

Position Responsibilities:

• Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity. Performs and handles inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations.
• Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria.
• Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals.
• Perform peer to peer reviews with providers when requested.
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.
• Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides.
• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
• Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frames.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Minimum Qualifications:

• Active, unrestricted, pharmacist license required
• 1+ years prior authorization review or appeals experience required
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities
• Have a designated workplace (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
• Strong oral and written communication skills required
• Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology)

Preferred Qualifications:

• Experience working with Medicare appeals preferred

All employees are responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance. 

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.

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.