Navitus Health Solutions is seeking a Supervisor, Prior Authorization Operations to join our Prior Authorization department!
The Supervisor, Prior Authorization Operations is responsible for organizing and supervising the daily operations of the prior authorization process and the prior authorization staff. The Supervisor, PAO is responsible for ensuring that formulary changes directed by the Pharmacy & Therapeutics Committee and changes driven by clients and regulatory or contractual requirements are implemented accurately and timely. This includes review of current processes against required processes, updating of work instructions, and other staff resources, ensuring effective training is delivered and Specialists comprehend and abide by changes, and maintaining a working knowledge of client, Medicaid, Medicare, URAC, and NCQA requirements. The Supervisor, PAO will be responsible for ensuring that the review and evaluation of drug prior authorization requests is conducted using approved clinical criteria, regulatory mandates, and client benefit information. This includes, but is not limited to, supervision of appropriate approvals by Specialists, transfer to a clinician when required, correct entry of overrides impacting claim adjudication and benefit accumulations, regulatory and compliance requirements, and accreditation requirements. The Supervisor, PAO will ensure that a qualified clinician makes all adverse coverage determinations, and that written communication is provided as required for adverse determinations which include the basis for determination and additional information required for consideration of reversing the determination.
Is this you? Find out more below!
ResponsibilitiesHow do I make an impact on my team?
Provide communications to clients, members, pharmacies, health care providers, and internal staff regarding the PA program and individual cases in a professional, clear, and concise mannerMaintain a working knowledge of compliance and regulation mandated by Medicare, Medicaid, Exchange, state, and accrediting bodies such as URAC and NCQA. This includes but is not limited to turnaround time requirement by line of business, client, and request type, outreach mandates, submission method requirements, Specialist qualification requirementsContinually evaluate the PA process and tools to identify and address opportunities for improvement in efficiency, accuracy, and appropriateness of the program. Use this evaluation to drive innovation to drive down manual processing volume or reduce handle timesAssist with setting and Monitor productivity measures/targets including turnaround time, phone answer timeliness, and first call resolutionEnsure Specialists are adequately skilled and trained to achieve productivity targets. Coach and train individuals not meeting targets and/or administer the discipline program up to and including termination when requiredConduct root cause analysis of audit failures, clients and Specialists, and provide recommendations for system and training improvements to close these gapsMaintain expert knowledge of client benefits, departmental and program processes, and PA case processingAssist in queue to ensure performance guarantees are met when there are staffing shortagesManage a team of up to 30 individuals including performing monthly one on one meetings, providing audit results, developing improvement plans, and developing career pathing opportunitiesOther duties as assigned QualificationsWhat our team expects from you?
A high school degree or equivalent required. Associate degree or 2 years relevant experience requiredMinimum of two years pharmacy, nursing, or managed care experience highly desirableRetail pharmacy experience, knowledge of the PBM industry, formulary management, pharmacy claims is desiredEmphasis is placed on proven experience demonstrating problem-solving skills, successful staff management and development, and experience interacting with clients to implement processes and resolve issuesProficiency in MS Word, Excel, and Power Point including use of tables, charts, and figures preferredParticipate in, adhere to, and support compliance program objectivesThe ability to consistently interact cooperatively and respectfully with other employeesWhat can you expect from Navitus?
Top of the industry benefits for Health, Dental, and Vision insurance20 days paid time off4 weeks paid parental leave9 paid holidays401K company match of up to 5% - No vesting requirementAdoption Assistance ProgramFlexible Spending AccountEducational Assistance Plan and Professional Membership assistanceReferral Bonus Program – up to $750!#LI-Remote
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