Director, Prior Authorization

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

📋 Description

• Provide overall leadership and strategic direction for the Prior Authorization department.

• Establish departmental goals, metrics, and priorities that align with organizational objectives.

• Build, develop, and mentor both leaders and team members.

• Lead efforts in workforce planning, succession planning, and organizational design.

• Promote service excellence, accountability, innovation, and continuous improvement.

• Oversee daily operations of Prior Authorization to ensure quality, efficiency, and timely service delivery.

• Develop and monitor key performance indicators (KPIs), service level agreements, and operational dashboards.

• Analyze departmental data to uncover trends, risks, and opportunities.

• Lead initiatives for process improvement and implement operational best practices.

• Ensure consistency and quality across all prior authorization activities.

• Manage relationships and performance expectations with clinical review vendors and external partners.

• Collaborate with vendors to enhance turnaround times, clinical consistency, and operational effectiveness.

• Support the implementation of programs, technologies, and clinical initiatives involving external partners.

• Align prior authorization processes with formulary strategies, utilization management objectives, and client requirements.

• Provide clinical and operational consultation regarding prior authorization programs.

• Utilize operational and clinical data to drive performance enhancements and strategic planning.

• Monitor industry trends, emerging technologies, and best practices in utilization management.

• Lead initiatives aimed at automation, efficiency, quality, and member satisfaction.

• Partner with Technology and Operations teams to optimize systems and workflows.

• Collaborate with Client Services, Operations, Member Care, Compliance, Technology, and Clinical teams.

• Participate in client implementations as the subject matter expert in prior authorization.

• Assist with client audits, reporting requests, and operational reviews.

• Ensure compliance with regulatory, accreditation, and client requirements.

• Maintain policies, procedures, and operational standards for prior authorization.

• Support quality assurance and audit activities.

• Identify and mitigate operational and compliance risks.

⛳️ Requirements

• Bachelor of Science in Pharmacy (BSPharm) or Doctor of Pharmacy (PharmD).

• Active pharmacist license in good standing.

• Minimum of 7-10 years of experience in pharmacy, clinical operations, prior authorization, utilization management, or related healthcare fields.

• At least 3-5 years of leadership experience with accountability for team performance and operational outcomes.

• Proven experience in leading people, processes, and complex operational initiatives.

• Strong analytical and problem-solving abilities.

• Experience in utilizing data to drive operational and business decisions.

• Excellent communication, presentation, and relationship management skills.

• Preferred experience in Pharmacy Benefit Management (PBM).

• Prior authorization leadership experience is preferred.

• Utilization management experience is preferred.

• Experience in multi-state operations is preferred.

• Familiarity with managing external clinical vendors is preferred.

• Experience leading large-scale process improvement initiatives is preferred.

• Lean, Six Sigma, or other related process improvement experience is preferred.

🏝️ Benefits

• A wide range of health insurance options, including medical, dental, and vision.

• A competitive salary and bonus program.

• A robust 401k plan with company matching.

• Employee Stock Ownership Plan (ESOP) with annual stock allocations.

• Employee Assistance Program.

• A wellness program that includes financial incentives, chiropractic and massage services, and fitness stipends.

• Dream Manager Program.

• A cohesive, family-oriented culture.

• Opportunities for charitable contributions and volunteer time.