Supervisor, Appeals Pharmacist

Capital Rx; New York (NY); On-site; USD 128,000 - 160,000; Full time

Job summary

Judi Health is seeking a subject matter expert in prior authorization and appeals to support multiple lines of business including Commercial, FEHB, Medicare Part B/D, and Medicaid. You will supervise appeal pharmacists and staff, ensure regulatory compliance, and drive performance and quality in PA operations.

You will analyze data, train staff, resolve escalated issues, and collaborate with Medicare and other partners to optimize workflows while handling day-to-day PA decisions and

Qualifications

• Doctor of Pharmacy or Bachelor of Pharmacy from an accredited program.
• Active unrestricted pharmacist license.
• 2 years of clinical pharmacist PBM experience.
• 1+ year working with Commercial and/or Medicare appeals.
• Strong PBM process knowledge: claims, formulary, PA, appeals.

Responsibilities

• Supervise a group of appeal pharmacists and technicians with PA admin functions.
• Oversight of appeal aids and clinical denial language.
• Analyze data with manager to forecast staffing and workflow needs.
• Train and onboard Appeals pharmacists; support ongoing education.
• Investigate/escalate issues from clients and providers.
• Collaborate with Medicare supervisor on staffing and workflows.
• Handle day-to-day PA and appeal reviews and provider education calls.
• Make clinical decisions per medical necessity and contract criteria.
• Evaluate literature to support provider decisions.
• Communicate with providers and members to improve outcomes.
• Manage PA queue and monitor compliance risk.

Skills

Prior Authorization

PBM processes

Leadership

Analytical skills

Microsoft Office

Education

Pharm.D.

Bachelor of Pharmacy

Tools

Microsoft Office Suite

Job description

About Judi Health

Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels. At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health.

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 prior authorization processes of prior authorization pharmacists, staff schedules, skilling, performance and managing compliance risks.

Position Responsibilities

• Responsible for supervision of a group of appeal pharmacists and technicians with expanded responsibility for select administrative PA functions.
• Oversight of appeal job aids and clinical denial language.
• Work in conjunction with Manager in analyzing available data and provide prior authorization staffing, workflow and system enhancement recommendations.
• Support on-going training of current staff and onboarding new Appeals pharmacists.
• Investigate/resolve escalated issues or problems from clients and providers.
• Works with appeal manager on other responsibilities, projects, implementations and initiatives as needed.
• Collaborate with Medicare supervisor to ensure appropriate staffing and develop workflow processes.
• Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
• Make clinical decisions in accordance with medical necessity and contract criteria
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers
• Communicate effectively with providers and members to promote positive health outcomes
• Handle inbound phone inquiries regarding prior authorization and or appeal requests.
• Review pharmacy claims data for proactive outreach and intervention
• Identify and monitor inappropriate trends in care to improve quality and cost effectiveness
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements
• Participates in the quality improvement committee and supports quality improvement projects as required by URAC (5-10% of time)
• Work with business and clinical partners as needed
• Ability to work in a fast-paced environment with shifting priorities
• Prior authorization queue management, supervise the daily operation of the queue, monitor for compliance risk and update skilling based on business needs

Minimum Qualifications

• A Doctor of Pharmacy (Pharm.D.) degree or Bachelor of Pharmacy degree from an accredited pharmacy program.
• An active unrestrictive pharmacist license.
• 2 years of experience as a clinical pharmacist in a Pharmacy Benefit Management (PBM) setting.
• 1+ year of experience working with Commercial and/or Medicare appeals.
• Strong understanding of pharmacy benefit management processes, including claims processing, formulary management, prior authorization, and appeals.
• Excellent analytical skills, showcasing an ability to analyze complex pharmacy claims and medical records, identify issues, and propose appropriate solutions.
• Strong leadership skills, including the ability to motivate and manage a team, provide guidance, and support, and foster a collaborative work environment.
• Proficiency in using Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
• Ability to work any shift EST Monday through Friday as well as on-call rotation for weekends, holidays, and after-hours.

Preferred Qualifications

• 1+ year of leadership experience in a remote environment.

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

New York, NY Salary Range: $128,000 — $160,000 USD

Denver, CO Salary Range: $117,600 — $147,000 USD

Charlotte, NC Salary Range: $106,800 — $133,500 USD

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We 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.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found athttps://www.judi.health/legal/privacy-policy.