Director, Pharmacy Coverage Reviews

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Oversee daily operations for prior authorization and appeals programs.

• Uphold and enforce clinical coverage policies in compliance with URAC, NCQA, and CMS standards.

• Guide and mentor managers and staff, establishing performance expectations and enhancing service quality and turnaround times.

• Analyze utilization trends, turnaround metrics, and appeal outcomes to pinpoint areas for improvement and support affordability initiatives.

• Collaborate with clinical strategy, pharmacy benefit management, and compliance teams to synchronize coverage review operations with enterprise objectives.

• Ensure that documentation and review activities comply with both internal and external audit standards, promoting enterprise compliance.

• Propel enhancements through the adoption of technology, optimization of workflows, and integration of best practices.

⛳️ Requirements

• Doctor of Pharmacy Degree (PharmD) is mandatory.

• At least 8 years of clinical experience is required.

• A minimum of 6 years of practical experience within a managed care setting is necessary.

• At least 4 years of supervisory or leadership experience is required.

• Capability to lead coverage review operations while ensuring compliance.

• Proficiency in policy implementation and understanding of regulatory standards.

• Competence in data analysis related to utilization trends and performance metrics.

• Strength in cross-functional collaboration to achieve operational alignment.

• Proven leadership in driving process improvements and team development.

• Must be licensed in Tennessee to practice Pharmacy or eligible for licensure in Tennessee.

• Familiarity with the Microsoft Office suite, including Microsoft Teams.

• Excellent organizational skills with the ability to manage multiple assignments or projects concurrently.

• Strong interpersonal skills along with effective oral and written communication abilities.

• Ability to responsibly utilize AI-enabled tools.

🏝️ Benefits

• Remote-first work arrangement.

• Remote positions available throughout the U.S., excluding California, Massachusetts, New Hampshire, New Jersey, and New York.

• Relocation assistance may be offered if the position necessitates residing in Chattanooga, TN.

• Proficiency in the Microsoft Office suite and Microsoft Teams is supported as part of the work environment.

• AI-enabled tools may be responsibly utilized to assist with daily tasks.