Manager, Utilization Management Oversight

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 internal and external oversight.

Position Responsibilities:

• Develop and maintain prior authorization policies and procedures for all lines of business compliant with federal, state, and other regulations
• Ensure prior authorization processes are adherent to URAC, NCQA, and other accrediting bodies
• Provide oversight on utilization management turnaround times to ensure compliance with regulations and accreditations
• Work with Commercial and Government PA managers to revise job aids, work instructions, verbiage templates and reference documents as needed
• Develop and maintain compliant prior authorization notifications for all lines of business including but not limited to approval and denial letter templates
• Represent PA team on audits from regulatory bodies including URAC, NCQA
• Support PA team on CDAG, ODAG, and data validation audits
• Stakeholder for prior authorization system to ensure compliance with all regulations
• Works with Senior Director, Prior Authorization on other responsibilities, projects, and initiatives as needed
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Minimum Qualifications:

• Active, unrestricted, pharmacist license required
• 1+ years prior authorization review or appeals experience required
• 2+ years of compliance or regulatory experience at a PBM or health plan required
• Extensive knowledge of how to operationalize Medicare, ERISA, and state-regulated prior authorization requirements required
• Strong oral and written communication skills required
• Intermediate to advanced Microsoft Excel skills required

Preferred Qualifications:

• Experience with Texas Department of Insurance (TDI) or other state-regulated markets
• NCQA and/or URAC accreditation experience preferred
• MS/MLS Health Law/Policy or JD with Pharm.D. preferred

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.

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