Job Description

Description

Rapidly Growing Player in the Pharmacy Benefits Management (PBM) marketplace seeks a Manager, Clinical Quality Assurance who will act as subject matter expert on prior authorization and appeals operations that are compliant for multiple lines of business.

Some of the expected job functions include:

• Develop and maintain prior authorization policies and procedures for all lines of business compliant with federal, state, and other regulations
• Ensure prior authorization processes are adherent to URAC, NCQA, and other accrediting bodies
• Work with Commercial and Government PA managers to revise job aids, work instructions, verbiage templates and reference documents as needed
• Support PA team on CDAG, ODAG, and data validation audits
• Manage Quality Assurance pharmacists and technicians
• Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed

The compensation plan includes a competitive salary ($145,000 - $155,000 d/o/e ), plus bonus and benefits.

This position can be filled “remotely”, or as “hybrid”, should the candidate live in the NYC-Metro area.

Requirements

The viable candidate for this position must have at least two (2) years of audit experience with CMS, NCQA, URAC, or any other national accrediting agency.

The ideal candidate for this position has at least two (2) years of prior authorization review and/or appeals experience in the Medicare space.

• Active, unrestricted, pharmacist license required (in good standing)
• 2+ years of compliance or regulatory experience at a PBM or health plan required
• Extensive knowledge of how to operationalize Medicare, ERISA, and state-regulated prior authorization requirements required
• Strong oral and written communication skills required
• Intermediate to advanced Microsoft Excel skills required

Qualified candidates should send their resumes in MS Word format to: mail@ phoenixhealthsearch.com

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