Lead, Clinical Prior Authorization Technician - Medicare

Position Summary:

Acts as a subject matter expert of prior authorization operations for Medicare lines of business and is primarily responsible for overseeing a group of prior authorization technicians in addition to providing support in day to day operations.

Position Responsibilities:

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  Responsible for overseeing a group of prior authorization technicians and expanded responsibility for select administrative PA functions.

  
  

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  Work in conjunction with the pharmacy technician supervisor in analyzing available data and provide prior authorization staffing, workflow and system enhancement recommendations.

  
  

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  Support on-going training and coaching of prior authorization pharmacy technicians

  
  

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  Participate in the goal setting process and regularly review performance of direct reports, addressing performance and behavioral issues when needed.

  
  

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  Investigate/resolve escalated issues or problems from clients and providers.

  
  

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  Works with prior authorization manager on other responsibilities, projects, implementations and initiatives as needed.

  
  

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  Review pharmacy claims data for proactive outreach and intervention.

  
  

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  Maintain quality and productivity standards for all cases triaged while minimizing compliance risk.

  
  

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  Work with business and clinical partners as needed.

  
  

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  Prepare prior authorization requests received by validating prescriber and member information, level of review, and appropriate clinical guidelines

  
  

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  Proactively obtains clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review.

  
  

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  Identify, document, and escalate provider concerns to the appropriate internal team including various members of the Prior Authorization Team

  
  

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  Triage phone calls from members, pharmacy personnel, and providers by asking applicable drug and client specific clinical questions.

  
  

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  Effectively communicate issues and resolutions to members, pharmacy staff, providers, and appropriate internal stakeholders.

  
  

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  Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies

  
  

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  Ensure customer satisfaction, extraordinary customer care, and quality resolution with genuine compassion in a fast paced, startup environment

  
  

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  Ability to work in a fast-paced environment with shifting priorities, and flexible schedules that may include weekends

  
  

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  Ability?to work flexible schedules that may include weekends

  
  

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  Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

  
  

Base Salary: $75,000 - $80,000

Nothing in this position description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation's electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp, Capital Rx is executing its mission through the deployment of JUDI, the company's cloud-native enterprise health platform, and a Single-Ledger Model, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.