Pharmacist Lead-Prior Authorization-BioPlus Specialty Pharmacy

BioPlus Specialty Pharmacy is now part of CarelonRx (formerly IngenioRx), and a proud member of the Elevance Health family of companies. Together, CarelonRx and BioPlus offer consumers and providers an unparalleled level of service that’s easy and focused on whole health. Through our distinct clinical expertise, digital capabilities, and broad access to specialty medications across a wide range of conditions, we deliver an elevated experience, affordability, and personalized support throughout the consumer’s treatment journey.

Location Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Pharmacist Lead-Prior Authorization-BioPlus Specialty Pharmacy a critical role that is central to ensuring the streamlined management of prior authorizations, handling denials, and managing appeals efficiently. Is responsible for overseeing daily business operations through mentoring pharmacists and providing leadership to non-clinical associates to maximize facility production in compliance with applicable regulations and promote cost effective drug use.

How you will make an impact:

• Manage and optimize the prior authorization process to ensure timely and cost-effective drug utilization.

• Address scheduling requirements and establish standards of practice for non-clinical associates involved in the prior authorization process.

• Navigate and resolve prior authorization denials efficiently, utilizing problem-solving skills to advocate and secure medication access for patients.

• Handle escalations and manage appeals for denied authorizations, ensuring thorough documentation and compliance with applicable regulations.

• Collaborate with interdisciplinary teams to improve processes and efficiency in managing prior authorizations and appeals.

• Stay updated with regulations and best practices related to prior authorizations to continually enhance operations and patient outcomes.

• Coordinates daily scheduling issues and standards of practice for clinical and non-clinical associates.

• Provides work direction, training and development of associate.

• Contributes input to performance reviews.

• Acts as a liaison and interacts with other functional areas to lead development of technical process updates.

• Supports team project.

• Leads the creation and filling of staffing models, based on business needs.

Minimum Requirements:

• Requires BA/BS in Pharmacy and a minimum of 3 years of experience in working with mail service operations related pharmacy experience; or any combination of education and experience, which would provide an equivalent background.

• Current valid active unrestricted RPH license to practice pharmacy in applicable states.

Preferred Skills, Capabilities, and Experiences:

• Specific knowledge of OIG, ERISA, HIPAA and regulatory environment, DSM / HEDIS Quality Improvement, and Clinical Interventions program strongly preferred.

• Experience as a Pharmacist Operational Expert preferred.

• Experience with Pharmacy prior authorization, denials, and  appeals strongly preferred.

• Extensive experience/knowledge in pharmacy operations and/or specialty pharmacy prior authorizations preferred.

• Experience in a leadership/support role preferred.

• Experience demonstrating strong written, oral, presentation and interpersonal communication skills strongly preferred.

For URAC accredited areas the following applies: Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.  minimum of 3 years' experience in working with mail service operations or related pharmacy experience; or any combination of education and experience, which would provide an equivalent background. Current valid active unrestricted RPH license to practice pharmacy in applicable states. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.