Lead Clinical Authorization and Appeals Specialist

7,000 Diseases - 500 Treatments - 1 Rare Pharmacy

PANTHERx is the nation’s largest rare disease pharmacy, and we put the patient experience at the top of everything that we do.

If you are looking for a career in the healthcare field that embraces authentic dedication to patient care, you don’t need to look beyond PANTHERx. In every line of service, in every position and area of expertise, PANTHERx associates are driven to provide the highest quality outcomes for our patients.

We are seeking team members who:

Are inspired and compassionate problem solvers;

Produce high quality work;

Thrive in the excitement of the ever-challenging environment of modern medicine; and

Are committed to achieving superior health outcomes for people living with rare and devastating diseases.

At PANTHERx, we know our employees are the driving force in what we do. We cultivate talent and encourage growth within PANTHERx so that our associates can continue to explore their interests and expand their careers. Guided by our mission to provide uncompromising quality every day, we continue our strategic growth to further reach those affected by rare diseases.

Join the PANTHERx team, and define your own RxARE future in healthcare!

Location: Pittsburgh, PA (Hybrid,)

Classification: Non-exempt

Status: Full-time

Reports to: Manager, RxARECARE Operations

Purpose

The Lead Clinical Authorization and Appeals Specialist plays a key role in leading the development, management, and oversight of the clinical authorization and appeal process within a RxARECARE team. This role supports the Lead Pharmacist, Supervisor and/or Manager of RxARECARE Program Operations in the execution of the prior authorization and appeal process, which includes ensuring tasks are completed daily and reviewing daily work assignments, acting as a mentor and resource to answer any process questions from the team, and participating in ongoing process improvement.

Responsibilities:

• Participates in program-specific process changes and provides training for new process changes.
• Schedules and distributes assigned responsibilities to team members daily.
• Ensures all prior authorization and appeal tasks are completed daily.
• Evaluates and acts on daily reports regarding prior authorizations and appeals, ensuring the team exceeds partner expectations.
• Ensures manufacturer business rules are followed regarding prior authorization and appeal processes.
• Supports team staffing efforts as necessary.
• Possesses a broad and deep understanding of assigned disease states, products, and clinical programs.
• Collaborates closely with program management team members as well as external stakeholders.
• Coordinates with other Leads and PANTHERx departments on escalations, as needed.
• Assists RxARECARE Supervisor with annual performance evaluations.
• Demonstrates appropriate judgment to be able to make independent clinical decisions.
• Fosters teamwork by encouraging collaboration at all levels within the organization.
• Additional projects and activities as assigned.

Required Qualifications:

• Associate degree or bachelor’s degree from an accredited nursing school as a Registered Nurse (RN).
• Demonstrated competence in community health or patient care setting, providing direct patient care for a minimum of two (2) years.
• Strong writing and grammar skills.
• Strong organizational skills and a thorough knowledge of Microsoft Office and Windows are required.
• Demonstrated ability to work independently and meet goals.

Preferred Qualifications

• Minimum of five (5) years as a practicing, licensed Registered Nurse (RN).
• Minimum of two (2) years of specialty pharmacy experience.

Work Environment

This position operates in a home or professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Physical Demands

While performing the duties of this job, the employee is regularly required to sit, see, talk, or hear. The employee frequently is required to stand; walk; use hands and fingers to handle or feel; and reach with hands and arms. Visual acuity is necessary for tasks such as reading or working with various forms of data. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of the job.

Benefits

Hybrid, remote and flexible on-site work schedules are available, based on the position. PANTHERx Rare Pharmacy also affords an excellent benefit package, including but not limited to medical, dental, vision, health savings and flexible spending accounts, 401K with employer matching, employer-paid life insurance and short/long term disability coverage, and an Employee Assistance Program! Generous paid time off is also available to all full-time employees, as well as limited paid time off for part-time employees. Of course we offer paid holidays too!

Equal Opportunity

PANTHERx Rare Pharmacy is an equal opportunity employer, and does not discriminate in recruiting, hiring, promotions or any term or condition of employment based on race, age, religion, gender, ethnicity, sexual orientation, gender identity, disability, protected veteran's status, or any other characteristic protected by federal, state or local laws.