Director, Prior Authorization

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process. Director, Prior Authorization Full Time Montvale, NJ, US 3 days ago Requisition ID: 1261 Director of Prior Authorization EmpiRx Health is the leading clinically-driven pharmacy benefits management company. As the pioneer in value-based pharmacy care, EmpiRx Health puts its customers and members first by enabling them to take control of their pharmacy benefits, healthcare outcomes, and financial results. We place more emphasis on member care than any other PBM by focusing on health outcomes first. Our pharmacists and clinicians are at the center of everything we do―and our population health solution delivers tailored strategies for our clients. Leveraging our newly launched, AI-powered pharmacy care platform, Clinically ™, EmpiRx Health’s pharmacists and client experience teams provide the highest quality pharmacy care to our clients and their members. This enables benefits plan sponsors to keep their members healthy, happy, and productive, while substantially reducing prescription drug spending, which has been on an explosive growth trajectory in recent years. The Director of Prior Authorization serves as the strategic and operational leader overseeing EmpiRx Health’s Prior Authorization and Appeals programs. This role manages a team of pharmacists and technicians responsible for clinical reviews, utilization management, and appeals processing while ensuring compliance with regulatory, clinical, and organizational standards. The Director will develop and optimize workflows, policies, and performance measures to drive operational excellence and ensure that prior authorization services deliver superior clinical quality and member satisfaction. As a key member of the Clinical Service/ Care Management leadership team, this individual will also partner cross-functionally with internal departments to advance efficiency, compliance, and innovation within EmpiRx Health’s utilization management framework. Key Responsibilities: Leadership and Team Management Lead and mentor a team of Prior Authorization Pharmacists and Technicians to deliver efficient, compliant, and high-quality clinical review services. Conduct performance evaluations, provide developmental feedback, and promote a collaborative, positive team culture. Partner with the Vice President of Clinical Services to design and implement strategies that enhance prior authorization effectiveness and scalability. Policy, Compliance & Quality Oversight Develop, implement, and maintain standard operating procedures (SOPs) and policies that comply with federal, state, and PBM regulations. Educate staff on changes in healthcare policy, pharmacy regulations, and EmpiRx Health internal procedures. Oversee clinical audits, ensure documentation accuracy, and lead corrective action initiatives as needed. Maintain high-quality performance by auditing cases for accuracy, completeness, and adherence to review guidelines. Operational Excellence & Reporting Monitor and analyze prior authorization performance metrics, turnaround times, and cost-savings impact. Develop and deliver regular operational and performance reports for internal leadership and external stakeholders. Leverage internal platforms (e.g., DOMO, Salesforce, Power BI) for workflow monitoring, trend analysis, and staff productivity tracking. Identify process inefficiencies and implement continuous quality improvement initiatives to streamline workflows and enhance member experiences. Cross-Functional Collaboration Partner with other EmpiRx Health departments (e.g., Client Management, Population Health, Analytics, and IT) to align strategies and processes that support clinical and operational goals. Provide clinical guidance and operational insights in support of client implementations, escalations, and renewals. Collaborate with formulary management and clinical programs teams to ensure integration of prior authorization policies and clinical initiatives. Clinical Expertise & Professional Development Stay informed of drug pipeline developments, clinical guidelines, and regulatory updates through continuous education and professional memberships. Use external resources such as IPD, UpToDate, and Medi-Span to support evidence-based clinical decision-making. Support staff training initiatives and promote ongoing professional certification and development among team members. Required Qualifications & Experience: Bachelor of Pharmacy degree from an accredited institution. 5+ years of prior authorization experience within a PBM or health plan setting. 10+ years of progressive management experience in healthcare or pharmacy operations. Strong understanding of utilization management, formulary compliance, and appeals processing. Advanced proficiency with Microsoft Office Suite (Excel, Word, PowerPoint) and pharmacy management systems. Demonstrated ability to lead cross-functional teams, manage complex workflows, and deliver measurable outcomes. Preferred Qualifications but Not Required PharmD preferred. MTM or specialty certification preferred. Experience with DOMO, Salesforce, or other analytics/reporting tools. Proven track record of managing hybrid or multi-location teams. Work Environment: Hybrid on-site in Montvale, NJ Compensation: 168-194K + 10% Bonus Subject to program eligibility, this position qualifies for a robust suite of benefits including Paid Time Off, a 401(k) program, Health Insurance including Dental & Vision coverage, Health Savings Account, and an Employee Assistance Program. EmpiRx Health is an Equal Opportunity Employer At EmpiRx Health, we wholeheartedly embrace the power of diversity and the magic of inclusion. The kaleidoscope of unique perspectives, backgrounds, and talents fuels our innovation and sets us apart. We're on a mission to build a team as diverse as the world we serve, where everyone is welcome and celebrated. We're not just breaking down barriers; we're actively erasing them to create an environment where opportunity knows no bounds. In unity, we find our strength and invite individuals from all walks of life to join us in our exhilarating journey to shape a brighter, more inclusive future together. Note: This job description is a general outline of responsibilities and qualifications for the role. Additional duties may be assigned, and the position may evolve to meet the organization's needs.Top of Form #J-18808-Ljbffr Empirx-Health-4