Manager, Clinical Quality Assurance - Medicare Prior Authorization

Position Summary:

Acts as subject matter expert on prior authorization and appeals operations that are compliant to federal, state, and other regulatory standards for multiple lines of business including Commercial, Commercial Exchange, FEHB, Medicare Part B&D, and Medicaid, and responsible for the oversight of quality initiatives including but not limited to prior authorization interreliability, internal audits, and external regulatory audits.

Position Responsibilities:

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  Develop and maintain prior authorization policies and procedures for all lines of business compliant with federal, state, and other regulations

  
  

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  Ensure prior authorization processes are adherent to URAC, NCQA, and other accrediting bodies

  
  

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  Implement quality assurance measures to ensure accuracy and consistency of prior authorization processes

  
  

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  Analyze and report quality findings to internal and external stakeholders

  
  

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  Work with Commercial and Government PA managers to revise job aids, work instructions, verbiage templates and reference documents as needed

  
  

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  Develop and maintain compliant prior authorization notifications for all lines of business including but not limited to approval and denial letter templates

  
  

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  Represent PA team on audits from regulatory bodies including URAC, NCQA

  
  

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  Support PA team on CDAG, ODAG, and data validation audits

  
  

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  Establish scheduled audit and reporting schedule for all quality assurance (QA) needs

  
  

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  Stakeholder for prior authorization systems to ensure compliance with all regulations

  
  

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  Manage Quality Assurance pharmacists and technicians

  
  

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  Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed

  
  

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  Pharmacy and Therapeutics (P&T) Committee participation as an ad hoc member. Conducts formulary reviews and drug monographs based on a rotation of clinical pharmacists

  
  

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

  
  

Minimum Qualifications:

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  Active, unrestricted, pharmacist license required

  
  

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  1+ years prior authorization review or appeals experience required

  
  

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  2+ years of compliance or regulatory experience at a PBM or health plan required

  
  

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  Extensive knowledge of how to operationalize Medicare, ERISA, and state-regulated prior authorization requirements required

  
  

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  Strong oral and written communication skills required

  
  

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  Intermediate to advanced Microsoft Excel skills required

  
  

Preferred Qualifications:

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  NCQA and/or URAC accreditation experience preferred

  
  

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  Juris Doctor (JD) degree (not required but a plus)

  
  

Base Salary: $145,000-$155,000

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.

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