Director, Prior Authorization

Develop, implement, and maintain standard operating procedures (SOPs) and policies that comply with federal, state, and PBM regulations.

Educate staff on changes in healthcare policy, pharmacy regulations, and EmpiRx Health internal procedures.

Oversee clinical audits, ensure documentation accuracy, and lead corrective action initiatives as needed.

Maintain high-quality performance by auditing cases for accuracy, completeness, and adherence to review guidelines.

Monitor and analyze prior authorization performance metrics, turnaround times, and cost-savings impact.

Develop and deliver regular operational and performance reports for internal leadership and external stakeholders.

Leverage internal platforms (e.g., DOMO, Salesforce, Power BI) for workflow monitoring, trend analysis, and staff productivity tracking.

Identify process inefficiencies and implement continuous quality improvement initiatives to streamline workflows and enhance member experiences.

Partner with other EmpiRx Health departments (e.g., Client Management, Population Health, Analytics, and IT) to align strategies and processes that support clinical and operational goals.

Provide clinical guidance and operational insights in support of client implementations, escalations, and renewals.

Collaborate with formulary management and clinical programs teams to ensure integration of prior authorization policies and clinical initiatives.

Stay informed of drug pipeline developments, clinical guidelines, and regulatory updates through continuous education and professional memberships.

Use external resources such as IPD, UpToDate, and Medi-Span to support evidence-based clinical decision-making.

Support staff training initiatives and promote ongoing professional certification and development among team members.

At EmpiRx Health, we wholeheartedly embrace the power of diversity and the magic of inclusion. The kaleidoscope of unique perspectives, backgrounds, and talents fuels our innovation and sets us apart. We're on a mission to build a team as diverse as the world we serve, where everyone is welcome and celebrated. We're not just breaking down barriers; we're actively erasing them to create an environment where opportunity knows no bounds. In unity, we find our strength and invite individuals from all walks of life to join us in our exhilarating journey to shape a brighter, more inclusive future together.

Note: This job description is a general outline of responsibilities and qualifications for the role. Additional duties may be assigned, and the position may evolve to meet the organization's needs.Top of Form