Director of Prior Authorization Services

Position Overview:

The Director of Prior Authorization Services leads the strategy, operations, and clinical integrity of the PBM’s prior authorization, coverage determination, and appeals programs across all lines of business. This leader ensures coverage decisions are timely, clinically sound, compliant with regulatory and accreditation requirements, and aligned with client plan designs, while improving the member and provider experience and driving operational efficiency..

About MedOne:

MedOne is a full-service pharmacy benefit manager (PBM), serving clients and members nationwide. With a fully transparent, pass-through model, MedOne helps people conveniently access the most appropriate prescriptions at the most affordable price.

What You Will Do at MedOne:

• Partner with Clinical, Formulary, Product, Compliance, Client Services, and Technology leadership to align PA criteria and workflows with formulary strategy and client needs.
• Evaluate and implement process improvements, automation, and new technologies (e.g., ePA, clinical decision support, AI-assisted review) to reduce turnaround times and manual effort.
• Oversee daily operations of PA intake, clinical review, determination, and appeals, including pharmacist, pharmacy technician, and support staff teams.
• Manage both administrative and clinical review responsibilities related to the prior authorization program, ensuring accuracy and completeness of reviews.
• Direct, train, and mentor team members including Clinical Review Pharmacists, Clinical Review Interns, Clinical Review Technicians, and Data Entry Specialists to ensure they are effectively performing in their responsibilities.
• Assess the quality and appropriateness of clinical treatments for the purpose of funding, identifying areas for improvement, and ensuring adherence to best practices.
• Manage the development and maintenance of clinical policies and procedures specific to the prior authorization program.
• Manage to defined service levels for turnaround time, accuracy, quality, and customer satisfaction.
• Monitor volumes, approval and denial trends, overturn rates, and cost impact; use data to forecast staffing, identify root causes, and recommend corrective actions.
• Manage departmental budget and resource planning.
• Manage vendor relationships and delegated entities, where applicable, including performance oversight and audits.
• Support client meetings, RFPs, and implementations by presenting PA program capabilities, performance results, and enhancements.
• Collaborate with provider and health plan partners to reduce administrative burden and improve access to appropriate therapy.
• Establish and oversee quality assurance programs, including inter-rater reliability, peer review, and case audits.
• Serve as an escalation point for complex, high-cost, or sensitive coverage determinations.
• Serves as Clinical Criteria Subcommittee Chair, conduct weekly criteria review meetings, and present recommendations for clinical review updates at the quarterly Pharmacy and Therapeutics committee meetings.
• Create clinical criteria by evaluating, reviewing and interpreting clinically accepted guidelines, peer-reviewed literature, and industry standards.
• Collaborate in the creation and implementation of client’s specific custom criteria and ensure custom criteria is used correctly with an emphasis on eliminating determination errors when custom criteria is used.
• Assist all teams in daily duties as needed including perform and complete outbound clinical consult calls with physicians, healthcare providers and/or patients.
• Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides; make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times; completing incoming review processes including fax management.
• Maintain readiness for client, regulatory, and accreditation audits (e.g., URAC, NCQA, CMS program audits); lead corrective action plans as needed.
• Support in the general operations of MedOne Clinical Services.
• Assist Member Advocate and Account Management teams with client, patient and/or provider requests.
• Serves as primary preceptor for the pharmacy student
• Promotes an inclusive and positive work environment consistent with MedOne’s Core Values.
• Assists and supports members of MedOne Pharmacy Benefit Solutions
• Portrays the company in a positive image
• Required to abide by all rules, regulations and policies of the employer
• Other duties as assigned

What you will bring to MedOne:

• Minimum of a Bachelor’s Degree in Pharmacy or PharmD with current unrestricted licensure as a pharmacist
• At least 2 years’ experience in a client facing or consultative role within the managed care or PBM setting
• Must be a strong communicator with the ability to translate clinical information into a manner appropriate for both clinical and non-clinical audiences
• High degree of emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
• Strong organizational, verbal and written communication skills with emphasis on attention to detail
• Proficient in drug literature and clinical trial evaluation
• Ability to work with a team
• Strong working knowledge of Microsoft Office products including Teams, Word, PowerPoint and Excel
• Knowledge of the PBM industry, formulary management, pharmacy claims and managed care principles and practices
• Residency experience is highly preferred

Why Join MedOne?

• Competitive salary and bonuses that reward your performance
• Comprehensive health, dental, and vision insurance
• 401(k) with company match to secure your future
• Generous paid time off and holidays
• Opportunities for professional growth and development
• A vibrant and collaborative work culture

Location: We have offices in either Dubuque, IA, or Kansas City, KS, or the position can be remote within the United States

Employment Type: Full-Time, Salary/Non-Exempt

Hours: Hours may vary within our normal business hours

How to Apply: If you're enthusiastic about helping others and eager to join a dynamic team, we’d love to hear from you. Apply now and take the first step toward a rewarding career at MedOne! You can submit your application through our careers page.

MedOne is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Job Offers are contingent on passing a background check and drug screen.

MedOne is an equal opportunity employer.

• 5+ years of experience in prior authorization operations, clinical services or related roles, with at least 2 years in a leadership position
• 3+ years of experience in pharmacy or pharmacy benefit management (PBM) preferred
• Proficient in Microsoft Office Suite and experience using clinical resources (Micromedex, Lexicomp, Clinical Pharmacology).
• Detail-oriented with a high degree of accuracy.
• Strong interpersonal, written, and verbal communication skills.
• Ability to work independently and manage time effectively.
• Excellent customer service and teamwork skills
• Must have a designated workplace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations (for remote employees)
• Familiarity with data entry software or CRM systems (Microsoft Dynamics) is a plus.
• Must be able to work independently, meets deadlines, establish priorities, and be flexible.