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Director Prior Authorization Jobs in Reston, VA (NOW HIRING)

MFA

Prior-Authorization Technician- Pharmacy

Arlington, VA · On-site

$23.46 - $30.50/hr

Under the direct supervision of a licensed Pharmacist: * Initiate prior authorizations for medications and work with providers on completion * Confirm patient demographics are accurate and insurance ...

MFA Co

Prior-Authorization Technician- Pharmacy

Arlington, VA · On-site

$20.25 - $24.50/hr

Under the direct supervision of a licensed Pharmacist: * Initiate prior authorizations for medications and work with providers on completion * Confirm patient demographics are accurate and insurance ...

VSI

Insurance Authorization Specialist

Reston, VA · On-site

$19 - $25.25/hr

This role is responsible for obtaining prior authorization for various medical procedures, services ... Works directly with the Director of Billing to identify trends in denials and opportunities for ...

CareMetx

Director, Pharmacy Operations

Bethesda, MD · On-site

$137K - $182K/yr

Director, Pharmacy Operations POSITION SUMMARY : We are seeking a strategic and operationally ... Prior authorization (PA) and appeals * Patient enrollment and case management * Operationalize ...

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Director Prior Authorization information

What is the difference between Director Prior Authorization vs Medical Claims Supervisor?

AspectDirector Prior AuthorizationMedical Claims Supervisor
Required CredentialsBachelor's degree, industry certifications often preferredBachelor's degree, relevant certifications beneficial
Work EnvironmentHealthcare organizations, insurance companiesHealthcare providers, insurance companies
Employer & Industry UsageUsed in health insurance and healthcare managementCommon in healthcare administration and insurance claims processing
Primary FocusReviewing and approving prior authorization requestsOverseeing claims processing and ensuring accuracy

The main difference is that the Director Prior Authorization focuses on managing the approval process for medical procedures before they occur, while the Medical Claims Supervisor oversees the processing and accuracy of claims after services are provided. Both roles require healthcare knowledge, but their responsibilities and workflows differ significantly.

What are the most commonly searched types of Prior Authorization jobs in Reston, VA?

The most popular types of Prior Authorization jobs in Reston, VA are:

Director Prior Authorization jobs near you

Prior Authorization Pharmacist

Accede Solutions Inc.

Mclean, VA • On-site

$59.75 - $71.75/hr

Other

Re-posted 28 days ago

Job description

Prior Authorization (PA) Pharmacist

The Prior Authorization (PA) Pharmacist would facilitate efforts in the review of clinical documentation and the Preferred Drug list (PDL) to determine proper medication therapy. The PA pharmacist will work with internal and external stakeholders in evaluating and continually developing a strategy for Utilization Management.

Responsibilities:

  • Clinical evaluation of medication therapy using established clinical or PDL criteria, drug compendia, and appropriate methods that support the principles of high-quality evidence-based medicine
  • Peer to Peer discussions with medical providers to discuss Prior Authorization reviews.
  • Consultations/Interventions: work with staff in contacting prescribers needing consultation to provide clinical information on prescribing practices that have been identified as outliers. Reviews prior authorizations data and determine opportunities for interventions.
  • Intervention Refinements: Collaborates on the refinement of consultation scripting; solicits and utilizes input from those contacted toward scripting improvements.
  • Operations: Contributes to the success of the Clinical Call Centers and Prior Authorization department by assisting with the implementation and management of both written and verbal communications to members and physicians. Is available for consultation on pharmacy-related questions and issues for others within the organization.
  • Quality Improvement: Contributes to program improvements by using continuous quality improvement processes, by being proactive in identifying improvement opportunities and by contributing on-going consultation and collaboration with product leaders.
  • Medical/Clinical: Upholds clinical integrity of pharmaceutical solutions by staying up to date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors, Clinical Pharmacist, and Clinical Specialty Pharmacist to provide pharmacy expertise.
  • Drug Review: Provides clinical input during the weekly drug file updates, making recommendations on applying utilization controls
  • Other duties as assigned. Contributes creative solutions to improve operational efficiency and effectiveness of pharmacy team

Qualifications:

  • Experience in the coordination of and collaboration of work teams preferred.
  • Ability to perform clinical reviews using relevant compendia and clinical trial data.
  • Managed care pharmaceutical service experience a plus.
  • Strong research and implementation skills in practical settings.
  • Analytical skills which can translate into practical and pragmatic recommendations.
  • Strong team orientation with respect for all members.
  • People skills are essential that allow for the successful consultation and collaboration with internal and external stakeholders who do not directly report to this job.

Requirements:

  • PharmD or B.S. in Pharmacy with relevant Specialty background
  • Registered Pharmacist with respective State Licensure
  • 4 years' experience in clinical pharmacy
  • Strong verbal and written communications skills.
  • Highly skilled with Microsoft office products and ability to quickly learn proprietary systems.

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