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Role Description

This role involves coordinating operational and cross-functional teams to deliver initiatives that optimize prior authorization (PA) operations through enhanced efficiency, regulatory compliance, training, and quality improvements.

• Demonstrate strong knowledge of clinical protocols, operational procedures, and systems used to support day-to-day prior authorization (PA), appeals, and related workflows.
• Serve as the key liaison within the PA team to ensure seamless implementation of process changes, system enhancements, and regulatory initiatives.
• Support operational and regulatory requirements and initiatives by coordinating cross-departmental implementation.
• Lead and/or contribute to preparations for compliance audits, accreditation documentation, government audits, and state audits.
• Coordinate with stakeholders to ensure new processes, procedures, regulations, and initiatives are clearly communicated, documented, and implemented.
• Interact, coordinate, and communicate with all levels of management including providers, stakeholders, and vendors.
• Support internal audits of PA and appeal case review by reviewing authorization accuracy and validating adherence to clinical policies.
• Other duties as assigned to support the overall goals and objectives of the Pharmacy Operations Team.

Qualifications

• Bachelor's degree required
• Minimum of 3 years of experience in the healthcare industry
• Experience must include focus in one or more of the following areas: Pharmacy operations, Prescription drug benefit administration, and/or Compliance functions
• Equivalent combination of education and experience will be considered
• Experience with health insurance, managed care, prior authorization (PA) processing, and/or prescription benefits
• Broad understanding and knowledge of state and federal rules and regulations
• Ability to coordinate activities with all levels of staff and external partners
• Strong analytical and conceptual skills to identify complex business problems
• Proficiency in using MS Office products and other corporate software
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

Requirements

• Ability to negotiate and resolve project and team issues with diplomacy and influence
• Experience in applying process improvement methodology to a project or process

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits
• Annual employer contribution to a health savings account
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays
• Market-leading retirement plan including a company match on employee 401(k) contributions
• Up to 12 weeks of paid parental time off
• Award-winning wellness programs that reward you for participation
• Employee Assistance Fund for those in need
• Commute and parking benefits