Position Responsibilities:

• Responsible for supervision of a group of clinical prior authorization pharmacists and expanded responsibility for select administrative PA functions.
• Oversight of 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 clinical prior authorization pharmacists.
• Participate in the goal setting process and regularly review performance of direct reports, addressing performance and conduct issues when needed.
• Investigate/resolve escalated issues or problems from clients and providers.
• Works with prior authorization manager on other responsibilities, projects, implementations and initiatives as needed.
• 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
• Provide backup support to call center team as required
• Review pharmacy claims data for proactive outreach and intervention
• Support staff training and development as required
• 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
• Work with business and clinical partners as needed
• Ability to work in a fast-paced environment with shifting priorities
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance
• Prior authorization queue management, supervise the daily operation of the queue, monitor for compliance risk and update skilling based on business needs

Required Qualifications:

• Active, unrestricted, pharmacist license required
• Bachelors or Doctor of Pharmacy Degree required
• 3+ years of experience as a clinical pharmacist in a Pharmacy Benefit Management (PBM) setting.
• 1+ year of leadership experience in a remote environment.
• Familiarity with relevant laws, regulations, and industry guidelines related to pharmacy benefit management.
• In-depth knowledge of pharmacy practice, including drug therapies, pharmacology, and clinical guidelines.
• Excellent written and verbal communication skills.
• 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.
• Excellent analytical skills, attention to detail, and ability to make evidence-based decisions.
• Proficiency in using Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
• Ability to work an evening schedule and rotating weekends
• Medicare prior authorization experience preferred

Base Salary: $130,000-$140,000

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to 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.