Senior Director, Prior Authorization Governance

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

📋 Description

• Lead the governance strategy for enterprise Prior Authorization across Medicare, Medicaid, Marketplace, Commercial, and Dual populations.

• Oversee the structures, frameworks for decision-making, and processes for approving changes to Prior Authorization requirements.

• Direct the biannual and annual reviews of PA rules, code lists, and authorization requirements at the enterprise level.

• Ensure that PA criteria are in line with evidence-based medicine, clinical best practices, and the objectives of the organization.

• Collaborate with Compliance, Legal, Medical Affairs, and Market Leadership to evaluate regulatory impacts and develop mitigation strategies.

• Support regulatory reviews such as Mental Health Parity that require oversight of PA governance.

• Analyze emerging trends and pinpoint opportunities for enhancing effectiveness and simplifying administration.

• Monitor the effects of PA policy changes and suggest corrective measures.

• Promote data-driven decision-making and initiatives for continuous improvement.

• Foster collaboration among Clinical Operations, Behavioral Health, Medical Affairs, Technology, Compliance, Finance, Analytics, Pharmacy, Market Operations, and Provider teams.

• Develop and mentor leaders tasked with governance, optimization, and program execution.

• Lead initiatives aimed at optimizing enterprise PA to lessen administrative burdens and enhance member and provider experiences.

• Support digital strategies for utilization management, automation projects, and AI-driven review capabilities.

⛳️ Requirements

• Bachelor’s degree in a relevant field or equivalent experience.

• Over 7 years of experience in product development, product management, or related fields.

• Familiarity with product planning, development, execution, and financial aspects of products.

• Experience across various market segments and product categories.

• More than 10 years of progressive leadership experience in healthcare.

• Expertise in Prior Authorization and Utilization Management.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase plans.

• Tuition reimbursement programs.

• Paid time off in addition to holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.

• Additional incentive options may be included in the overall compensation package.