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Job Summary:
Oversees daily operations, staff, workflows, and clinical/operational performance of the pharmacy prior authorization (PA) program. This role ensures efficient, compliant, and patienta'centered management of medication authorization processes across ambulatory and specialty pharmacy services. The manager collaborates closely with clinicians, payers, revenue cycle, care teams, and pharmacy leadership to reduce barriers to medication access, optimize turnaround times, and drive standardization and quality.
Responsibilities:
- Manage enda'toa'end prior authorization workflows, including intake, benefit investigation, clinical review coordination, submission, followa'up, and appeals.
- Develop, implement, and monitor productivity, quality, and turnaround-time standards.
- Oversee staffing models, scheduling, workload distribution, and resource planning.
- Maintain current expertise in payer requirements, coverage rules, specialty medication pathways, and regulatory obligations.
- Partner with IT/EMR teams to optimize PAa'related tools, automation, and documentation workflows.
- Supervise PA specialists, technicians, and/or pharmacists involved in authorization processes.
- Recruit, onboard, coach, and evaluate staff performance.
- Provide ongoing education regarding payer policies, clinical criteria, and operational standards.
- Foster a culture of service excellence, collaboration, and continuous improvement.
- Serve as primary operational liaison to clinics, providers, specialty pharmacists, and payers.
- Ensure timely escalation and resolution of higha'impact or urgent patient access issues.
- Oversee the appeals process and ensure regulatorya'compliant documentation.
- Monitor KPIs such as turnaround times, approval rates, appeal outcomes, productivity, and patient wait times.
Qualifications/Requirements:
Experience:
- At least 35 years of experience in pharmacy operations, prior authorization, utilization management, or specialty pharmacy.
- Experience supervising or managing staff.
- Strong knowledge of commercial, Medicare, and Medicaid payer requirements.
- Experience in ambulatory care or healtha'system specialty pharmacy.
Education:
- Bachelors degree in Pharmacy, Health Administration, Business, or related field (pharm tech or pharmacy backgrounds strongly preferred).
Licenses / Certifications:
- PharmD or CPhT certification.
Other:
