Location: Remote (For Non-Local) or Hybrid (Local to NYC area)

Position Responsibilities:

• Responsible for overseeing a group of prior authorization technicians and expanded responsibility for select administrative PA functions.
• Work in conjunction with the pharmacy technician manager in analyzing available data and provide prior authorization staffing, workflow and system enhancement recommendations.
• Support on-going training and coaching of utilization management pharmacy technicians.
• Participate in the goal setting process and regularly review performance of direct reports, addressing performance and behavioral issues when needed.
• Investigate/resolve escalated issues or problems from clients and providers.
• Works with utilization management manager on other responsibilities, projects, implementations and initiatives as needed.
• Review pharmacy claims data for proactive outreach and intervention.
• Maintain quality and productivity standards for all cases triaged while minimizing compliance risk.
• Work with business and clinical partners as needed.
• Prepare prior authorization requests received by validating prescriber and member information, level of review, and appropriate clinical guidelines.
• Proactively obtains clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review.
• Identify, document, and escalate provider concerns to the appropriate internal team including various members of the utilization management team.
• Triage phone calls from members, pharmacy personnel, and providers by asking applicable drug and client specific clinical questions.
• Effectively communicate issues and resolutions to members, pharmacy staff, providers, and appropriate internal stakeholders.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies.
• Ensure customer satisfaction, extraordinary customer care, and quality resolution with genuine compassion in a fast paced, startup environment.
• Ability to work in a fast-paced environment with shifting priorities, and flexible schedules that may include weekends.
• Ability to work flexible schedules that includes an on-call weekend and holiday rotation.

Required Qualifications:

• At least 1 year of Medicare experience, including working knowledge of policies and guidelines
• Minimum 1 year of Medicare Prior Authorization and/or Medicare appeals experience
• Demonstrated ability to communicate effectively and manage team priorities
• Strong organizational and problem-solving skills
• Active, unrestricted, National Certified Pharmacy Technician (CPhT) license required
• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel and PowerPoint
• Strong clinical background required
• Excellent communication, writing, and organizational skills
• Ability to multi-task and collaborate in a team with shifting priorities

Preferred Qualifications:

• 2+ years of leadership experience
• Strong understanding of CMS regulations and payer requirements
• 2+ years of PBM or Managed Care pharmacy experience