United States onlyCompany
NavitusAbout Us
Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.. Current associates must use SSO login option at https://employees-navitus.icims.com/ to be considered for internal opportunities.Pay Range
USD $55,150.89 - USD $66,447.35 /Yr.Work Schedule Description (e.g. M-F 8am to 5pm)
VariesRemote Work Notification
ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.Overview
Navitus Health Solutions is seeking a Supervisor, Prior Authorization Operations to join our Prior Authorization department!
The Supervisor, Prior Authorization Operations is responsible for organizing and supervising the daily operations of the prior authorization process and the prior authorization staff. The Supervisor, PAO is responsible for ensuring that formulary changes directed by the Pharmacy & Therapeutics Committee and changes driven by clients and regulatory or contractual requirements are implemented accurately and timely. This includes review of current processes against required processes, updating of work instructions, and other staff resources, ensuring effective training is delivered and Specialists comprehend and abide by changes, and maintaining a working knowledge of client, Medicaid, Medicare, URAC, and NCQA requirements. The Supervisor, PAO will be responsible for ensuring that the review and evaluation of drug prior authorization requests is conducted using approved clinical criteria, regulatory mandates, and client benefit information. This includes, but is not limited to, supervision of appropriate approvals by Specialists, transfer to a clinician when required, correct entry of overrides impacting claim adjudication and benefit accumulations, regulatory and compliance requirements, and accreditation requirements. The Supervisor, PAO will ensure that a qualified clinician makes all adverse coverage determinations, and that written communication is provided as required for adverse determinations which include the basis for determination and additional information required for consideration of reversing the determination.
Is this you? Find out more below!
Responsibilities
How do I make an impact on my team?
- Provide communications to clients, members, pharmacies, health care providers, and internal staff regarding the PA program and individual cases in a professional, clear, and concise manner
- Maintain a working knowledge of compliance and regulation mandated by Medicare, Medicaid, Exchange, state, and accrediting bodies such as URAC and NCQA. This includes but is not limited to turnaround time requirement by line of business, client, and request type, outreach mandates, submission method requirements, Specialist qualification requirements
- Continually evaluate the PA process and tools to identify and address opportunities for improvement in efficiency, accuracy, and appropriateness of the program. Use this evaluation to drive innovation to drive down manual processing volume or reduce handle times
- Assist with setting and Monitor productivity measures/targets including turnaround time, phone answer timeliness, and first call resolution
- Ensure Specialists are adequately skilled and trained to achieve productivity targets. Coach and train individuals not meeting targets and/or administer the discipline program up to and including termination when required
- Conduct root cause analysis of audit failures, clients and Specialists, and provide recommendations for system and training improvements to close these gaps
- Maintain expert knowledge of client benefits, departmental and program processes, and PA case processing
- Assist in queue to ensure performance guarantees are met when there are staffing shortages
- Manage a team of up to 30 individuals including performing monthly one on one meetings, providing audit results, developing improvement plans, and developing career pathing opportunities
- Other duties as assigned
Qualifications
What our team expects from you?
- A high school degree or equivalent required. Associate degree or 2 years relevant experience required
- Minimum of two years pharmacy, nursing, or managed care experience highly desirable
- Retail pharmacy experience, knowledge of the PBM industry, formulary management, pharmacy claims is desired
- Emphasis is placed on proven experience demonstrating problem-solving skills, successful staff management and development, and experience interacting with clients to implement processes and resolve issues
- Proficiency in MS Word, Excel, and Power Point including use of tables, charts, and figures preferred
- Participate in, adhere to, and support compliance program objectives
- The ability to consistently interact cooperatively and respectfully with other employees
What can you expect from Navitus?
- Top of the industry benefits for Health, Dental, and Vision insurance
- 20 days paid time off
- 4 weeks paid parental leave
- 9 paid holidays
- 401K company match of up to 5% - No vesting requirement
- Adoption Assistance Program
- Flexible Spending Account
- Educational Assistance Plan and Professional Membership assistance
- Referral Bonus Program – up to $750!
