What are the responsibilities and job description for the Director, Pharmacy Utilization Management position at Curative?
The Director of Prior Authorization Pharmacy is responsible for leading and overseeing the prior authorization (PA) pharmacy team and ensuring operational excellence in clinical review processes, appeals management, and formulary compliance. This role provides strategic leadership, enhances workflow efficiencies, and ensures compliance with regulatory requirements while driving continuous improvement initiatives. The Director will also collaborate cross-functionally to optimize pharmacy benefits and utilization management strategies, aligning with Curative’s vision for patient-centered care.
This is a REMOTE Position with Pharmacy Licensure Requirements
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Develop and implement strategic goals for the prior authorization pharmacy team to align with the organization’s healthcare vision.
- Oversee and lead a team of prior authorization pharmacists and pharmacy technicians, providing mentorship, training, and professional development.
- Establish and maintain quality assurance programs to ensure compliance with regulatory and organizational requirements.
- Serve as a key liaison between the pharmacy team and cross-functional departments, including Medical Management, Retail Pharmacy, Formulary, Compliance, and Customer Care.
- Ensure efficient and timely completion of prior authorization reviews, adverse determinations, and appeals, adhering to state and federal regulatory requirements.
- Oversee the resolution of complaints related to prior authorization and formulary adherence.
- Collaborate with PBMs and external stakeholders to ensure the accuracy of claim adjudications and benefit alignment.
- Provide consultation and partnership to the Curative Formulary Team for clinical guidance and policy updates to support pharmacy benefit design and disease management programs.
- Analyze prior authorization and appeals data to identify trends, recommend process improvements, and enhance patient outcomes.
- Participate in the Pharmacy & Therapeutics (P&T) Committee to review and maintain an up-to-date drug formulary.
- Oversee the development of standard operating procedures (SOPs) for PA processes and operational workflows.
- Work closely with Medical Directors and interdisciplinary teams to enhance pharmacy utilization management programs.
- Develop clear communication strategies for member and provider engagement regarding prior authorization decisions and formulary updates.
- Support disease management initiatives (e.g., adherence, diabetes management, weight management) by integrating pharmacy services into broader health plan strategies.
- Represent the pharmacy department in interdisciplinary team (IDT) meetings, identifying high-risk cases and optimizing interventions.
- Ensure compliance with state and federal regulations, including CMS, NCQA, and URAC standards.
- Monitor and report key performance indicators (KPIs) related to prior authorization turnaround times, appeals outcomes, and adherence metrics.
- Support internal and external audits related to prior authorization and pharmacy benefit operations.
- Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc.).
- A portion of day-to-day responsibilities of this position will include conducing prior authorization reviews.
- This position assumes and performs other duties as assigned.
- Work hours Mon-Friday and some Saturdays.
QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions :
Required
Preferred Qualifications
EDUCATION and / or EXPERIENCE
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to sit; use hands to handle or feel; talk; and hear.
For this position the percentage of expected Travel is : 5% of the time
