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Capital Rx · 11 hours ago

Senior Director, Prior Authorization & Clinical Care Operations

Denver, CO

Full-time

Onsite

Director/Executive

$170K/yr - $185K/yr

8+ years exp

Judi Health is an enterprise health technology company focused on providing comprehensive solutions for employers and health plans. They are seeking a Senior Director to oversee Prior Authorization Operations, ensuring efficiency and compliance while leading a large team and driving strategic initiatives across multiple lines of business.

Hospital & Health Care

Responsibilities

Define and execute the strategic vision for Prior Authorization and Clinical Care Operations teams across all lines of business (Commercial, Medicare, Exchange, Medicaid, etc.) in alignment with overall company objectives

Lead the development and implementation of long-term goals to improve workflow and efficiency while maintaining high-quality standards

Lead and develop a large team of pharmacists, technicians, and support staff to deliver efficient and accurate Prior Authorization and Clinical Care operations

Champion the adaption of advanced automations to improve accuracy, efficiency, and decision making

Lead and manage client needs, requests, and meetings as it pertains to the Prior Authorization and Clinical Care functions including leading and actively participating in calls with clients, consultants, and other external stakeholders

Serve as a liaison with internal stakeholders, including other departments in Clinical Operations, to ensure transparency, collaboration, and effective communication regarding Prior authorization and Clinical Care operations and requirements

Ensure that Prior Authorization and Clinical Care processes comply with regulatory standards, including URAC, NCQA, and federal and state guidelines, managing risks associated with compliance, regulatory audits, and industry certifications

Support the development of Capital Rx’s formulary management platform

Provide strategic direction and mentorship to PA leadership to foster a culture of collaboration, professional growth, accountability, and team success

Drive the development of KPIs and performance metrics for the PA department, ensuring that progress is measured against both departmental and organizational goals

Prepare and present executive-level reports, highlighting key performance trends, challenges, and recommendations for improvement

Key stakeholder and SME for Prior Authorization to the development team to implement advanced solutions that increase operational agility

Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance

Qualification

Pharmacist licenseDoctor of PharmacyPrior Authorization experienceLeadership experiencePharmacy regulations knowledgeClient facing experienceData analysis proficiencyMicrosoft Office SuiteCommunication skillsProblem-solving skillsTeam management

Required

Active, unrestricted pharmacist license required

Doctor of Pharmacy degree required

8+ years of experience in Prior Authorization or Utilization Management at a PBM, health plan, or healthcare provider organization

5+ years of leadership experience, including direct supervision in a complex, multi-functional environment

Proven track record of leading large teams and managing complex prior authorization and clinical care operations

Strong knowledge of pharmacy regulations, accreditation standards, and compliance requirements

Client facing experience required

Experience in overseeing multiple lines of business including Commercial, Exchange, and Medicare

Experience in managing Clinical Call Center operations and integrating customer service teams

Proven ability to define and execute strategic operational plans for large-scale operations at a senior leadership level, translating organizational strategy into actionable department-level initiatives

Strong financial acumen including the ability to manage unit cost

Innovative problem-solver with a continuous improvement mindset

Strong proficiency in data analysis and performance reporting, with the ability to leverage insights for decision-making

Excellent communication skills, both written and verbal, with significant experience in presenting to executive leadership

Proficiency in Microsoft Office Suite and familiarity with other advanced data and reporting tools (e.g., Tableau, Power BI, etc.)

In-depth understanding of regulatory compliance and industry standards such as URAC, NCQA, and federal/state requirements

Ability to work effectively in a fast-paced, evolving environment and manage complex, cross-functional teams