A proud member of the Elevance Health family of companies, CarelonRx leverages the power of new technologies and a strong, clinical-first lens, to deliver member-centered, lasting pharmacy care.
Accountable for all oversight of the pharmacy prior authorization operations, including the approval or denial of medications pursuant to coverage under the patient's benefit plan and established clinical criteria. We are seeking a highly skilled and experienced Senior Clinical Leader for our Pharmacy Prior Authorization Operations team. The ideal candidate will be responsible for leading and managing the day-to-day operations of the prior authorization process within the pharmacy department, ensuring efficiency, accuracy, and compliance with relevant regulations and standards.
Team Scope
9 direct reports and a total organization of approximately 270 associates.
Position Responsibilities
Leadership and Management:
Provide vision and direction for the pharmacy prior authorization operations team.
Oversee the recruitment, training, and development of staff.
Foster a collaborative and productive working environment to drive team performance.
Operations Oversight:
Manage the end-to-end prior authorization process to ensure timely and accurate processing of requests.
Develop, implement, and continuously improve operational workflows and processes.
Monitor key performance indicators (KPIs) and metrics to ensure operational efficiency and effectiveness.
Compliance and Quality Assurance:
Ensure compliance with federal, state, and local regulations, as well as company policies and standards.
Conduct regular audits and quality checks to maintain high standards of service.
Address any issues or discrepancies in the authorization process promptly and effectively.Strategic Planning and Execution:
Establish strategic goals and objectives for the prior authorization operations.
Implement best practices and innovative solutions to optimize resource utilization and improve service delivery.
Liaise with other departments, such as IT, finance, and clinical teams, to integrate and align operational goals.
Customer and Stakeholder Relations:
Act as the primary point of contact for internal and external stakeholders regarding prior authorization processes.
Collaborate with healthcare providers, insurance companies, and patients to resolve authorization issues.
Ensure excellent customer service and satisfaction through responsive and proactive communication.
Data Analysis and Reporting:
Utilize data analytics to identify trends, pinpoint bottlenecks, and drive performance improvements.
Prepare and present regular reports on operational performance and outcomes to senior management.
Position Requirements
Requires BA/BS in Pharmacy and a minimum of 8 years of experience in the PBM clinical pharmacy initiatives which includes a minimum of 3 years of management experience in leading clinical professionals and experience with P & T committees; or any combination of education and experience, which would provide an equivalent background. Must possess a current active valid unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh).
Preferred Skills, Capabilities and Experiences
Minimum of 7-10 years of experience in pharmacy operations, with a focus on prior authorization.
A strategic thinker with proven success in a leadership role, managing large teams and complex workflows.
Strong understanding of healthcare regulations, insurance processes, and prescription drug protocols.
Excellent analytical, problem-solving, and decision-making skills.
Outstanding communication and interpersonal abilities.
Proficiency in using healthcare management software and tools.
For candidates working in person or remotely in the below locations, the salary* range for this specific position is $171,600. to $318,880.
Location: Hybrid In-office 3+ days a week. The ideal candidate will be within a 50-mile commuting distance of an Elevance Health office, preferably in Indianapolis, IN, Woodland Hills, CA, Atlanta, GA, Mason, OH, Norfolk, VA, or Richmond, VA.
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
