The supervisor is responsible for providing operational leadership and direction for Prior Authorization and Appeals business units.
The position has a primary focus on ensuring compliance with all state regulations. Other key areas of focus include quality improvement,innovation and reduction of unit costs. Responsibilities of the position include daily operational oversight, staff development, budget management,audit readiness, staff training documentation and execution and policy and procedure documentation.
The leader will work with internal partners and the PA staff to ensure ability to service physicians, pharmacists and patients within service levels and provide for appropriate clinical drug therapies. Essential functions of the job include:
Lead the PA and Appeals operational unit including ensuring regulatory compliance with state rigs regarding the processing of prior authorizations and appeals.
Ensure standardization and consistency in practices, procedures and workflow to improve efficiency and quality.
Coordinate with IROs and IRE external organization to ensure business requirement are met.
Develop an annual business plan for the department to include revenue and expense forecasts, resource justifications and performance analysis of the department.
Understand and ensure end to end regulatory compliance with all state, federal and other regulatory and client requirements.
Work with Compliance, Legal, and Account Management, IT, Clinical Development and various internal departments to coordinate operational initiatives that achieve compliance.
Work with peers and staff to ensure understanding and execution of operational and business requirements. Ensure staff is help accountable to quality, training and production metrics.
Ensure processes are documented and trained. Run day to day operations for PA and Appeals.
Represent the Medicaid Ops process through client facings, client work group meetings and work with clients when needed regarding implementation and ongoing maintenance of their business.
Highly skilled in leading significant change efforts and in building strong partnerships with business-line executives. Ability to summarize complex issues and problems into a concise report, focused on key findings and outcomes; Proficiency in developing communication strategies for a wide array of audiences that support strategic objectives; Demonstrated sophisticated written and verbal presentation abilities; substantial experience with the development of presentation materials (collateral, proposals, presentations, talking points, etc.); proficiency in the management of time, flexibility, and influencing colleagues to meet demanding project timelines.
CPhT, PTCB, Customer Service, Pharmacy Technician, Mail Order, Specialty, CVS, Mail, Insurance Verification, Processing Technician
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