Supervisor, Medicare Prior Authorization

Navitus Health Solutions is seeking a Medicare Prior Authorization Supervisor to join our team!

The Supervisor, Medicare Prior Authorization (SMPA) is responsible for organizing and supervising the daily operations of the Medicare Coverage Determination process and the Medicare Prior Authorization Specialists. The SMPA is responsible for ensuring that changes driven by clients and CMS Regulatory requirements are implemented accurately and timely. This includes review of current processes against required processes, updating of work instructions and other staff resources, ensuring effective training is delivered and the Medicare Specialists comprehend and abide by the changes. The SMPA will maintain a working knowledge of Medicare, CMS and NCQA requirements. The SMPA will actively participate in internal and external Medicare audits including presentations, deliverables and execution of any CAPs or process changes that result from the audit. The SMPA ensure the Medicare Specialists are meeting individual and team performance goals and maintain accuracy through audit monitoring.

Is this you? Find out more below!

How do I make an impact on my team?

Provide audit support for all CMS audits, Delegation audits, client audits and internal audits related to Coverage Determinations. This includes presentation, deliverables, and execution of any CAPs
• Maintain a working knowledge of compliance and regulation mandated by Medicare/CMS and accrediting bodies such as URAC and NCQA. This includes but is not limited to turnaround time requirement, client, and request type, outreach mandates, submission method requirements, Specialist qualification requirements
• Develops and maintains deep subject matter expertise related to Medicare Part D rules and regulations specific to Coverage Determinations, Redeterminations, and IRE processes
• Maintain working knowledge of CMS reports related to Coverage Determinations. This includes the ability to investigate and troubleshoot data contained within these reports as well as an understanding of how the Medicare PA processes impact the data for these reports
• Monitors and interprets CMS regulations, guidance, and system changes. Ensures the Medicare Part D Prior Authorization functions meets all regulatory requirements
• Manages the development, implementation, and maintenance of Medicare Part D Prior Authorization processes for all Medicare Part D clients that delegate Prior Authorization to Navitus. Implements requirements utilizing project management
• Support Member, Provider, client, or other escalations related to Coverage Determinations. Ability to support escalations via phone, email, meeting, or in writing
• Assist in queue to ensure performance guarantees are met when there are staffing shortages. This includes after hour and weekend support when needed
• Actively engage in any system changes impacting Prior Authorization. This includes knowledge, training, defining processes, creating resources, testing, ensuring system meets all regulatory and client requirements, and oversight processes
• Manage a team of up to 30 individuals including performing monthly one on one meetings, providing audit results, developing improvement plans, and developing career pathing opportunities
• Other duties as assigned

What our team expects from you?

• A high school degree or equivalent is required
• A Bachelor's Degree or 2 years supervisor experience required
• Experience and expertise in Medicare Part D highly preferred
• Minimum of two years pharmacy or PBM industry highly desirable
• Emphasis is placed on proven experience demonstrating problem solving skills, successful staff management and development and experience interacting with clients to implement processes and resolve issues
• Experience in Medicare audits highly desired
• Possess working knowledge of MS Word, Excel, Outlook, and PowerPoint
• Some travel may be required
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance

• 20 days paid time off

• 4 weeks paid parental leave

• 9 paid holidays

• 401K company match of up to 5% - No vesting requirement

• Adoption Assistance Program

• Flexible Spending Account

• Educational Assistance Plan and Professional Membership assistance

• Referral Bonus Program - up to $750!

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