Prior Authorization Pharmacist, Appeals ID-3452
Senior Analyst(s) will be responsible for end-to-end business process activities - creating, controlling and improving the performance guarantee processes related to Prior Authorization and Appeals.
They will lead process design and project implementation teams to assure program compliance and quality control for adherence to audit requirements based on governing bodies for the 19 states serviced by Health Care Company Community and State.
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Key Responsibilities:
Responsible for diagnosing process improvement opportunities and developing solutions using principles of process excellence and related tools.
Quality reporting, analysis, audits and for developing plans and programs to support continuous quality improvement using applicable tools.
May assist in the creation, implementation, and evaluation of Total Quality Management (TQM) programs surrounding PA and Appeal related performance guarantees.
May direct design, facilitation, training and evaluation of TQM incentive programs and may oversee quality improvement projects and teams in functional area.
The Prior Authorization Governance and Auditing Group provides audit and regulatory support related to Prior Authorization and Appeals for all clients of OptumRx.
The analyst(s) will serve as the regulatory subject matter expert during oversight and delegation audits performed by various clients.
Analyst(s) will be responsible to analyze and report OOC data, perform clinical review on all DOI inquiries to ensure the PA and appeal process are aligned with regulatory guidance.
Analyst(s) will lead data validation efforts for PA and Appeals including quality control for adherence to accreditation, state and federal program requirements.
Clinical validation includes review of prior authorization cases for clinical decision-making based on individual plan formulary and requirement and patient demographics.
The analyst(s) will ensure compliance to various regulations based on lines of business and plan design.
In addition to audit support, the analyst(s) will be involved with trending to identify process improvements to ensure compliance with applicable state and federal laws, business contract requirements, prevent untimely cases and maintain client relations.
Analyzes and investigates root cause of non-compliant cases.
Compensation:
Hourly W2 pay rate $ We have access to additional contract, contract-to-hire, and direct hire positions with various rate ranges.
If you have the described qualifications and are interested in this exciting opportunity, apply today! Ranked a Top Staffing Firm in the U.S.
by Staffing Industry Analysts for six consecutive years, Genesis10 puts thousands of consultants and employees to work across the United States every year in contract, contract-for-hire, and permanent placement roles.
With more than 300 active clients, Genesis10 provides access to many of the Fortune 100 firms and a variety of mid-market organizations across the full spectrum of industry verticals.
For contract roles, Genesis10 offers the benefits listed below.
If this is a perm-placement opportunity, our recruiter can talk you through the unique benefits offered for that particular client.
Benefits of Working with Genesis10:
Access to hundreds of clients, most who have been working with Genesis10 for 5-20+ years.
The opportunity to have a career-home in Genesis10; many of our consultants have been working exclusively with Genesis10 for years.
Access to an experienced, caring recruiting team (more than 7 years of experience, on average.) Behavioral Health Platform Medical, Dental, Vision Health Savings Account Voluntary Hospital Indemnity (Critical Illness & Accident) Voluntary Term Life Insurance 401K Sick Pay (for applicable states/municipalities) Commuter Benefits (Dallas, NYC, SF) Remote opportunities available For multiple years running, Genesis10 has be n recognized as a Top Staffing Firm in the U.S., as a Best Company for Work-Life Balance, as a Best Company for Career Growth, for Diversity, and for Leadership, amongst others.
Genesis10 is an Equal Opportunity Employer.
Candidates will receive consideration without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
