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

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

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