Director, Prior Authorization

Director of Prior Authorization Empi Rx  Health is the leading clinically-driven pharmacy benefits management company. As the pioneer in value-based pharmacy care, Empi Rx Health puts its customers and members first by enabling them to take control of their pharmacy benefits, healthcare outcomes, and financial results.

We place more emphasis on member care than any other PBM by focusing on health outcomes first. Our pharmacists and clinicians are at the center of everything we do—and our population health solution delivers tailored strategies for our clients. Leveraging our newly launched, AI-powered pharmacy care platform, Clinically ™ , Empi Rx Health’s pharmacists and client experience teams provide the highest quality pharmacy care to our clients and their members.

This enables benefits plan sponsors to keep their members healthy, happy, and productive, while substantially reducing prescription drug spending, which has been on an explosive growth trajectory in recent years.

The Director of Prior Authorization serves as the strategic and operational leader overseeing Empi Rx Health’s Prior Authorization and Appeals programs. This role manages a team of pharmacists and technicians responsible for clinical reviews, utilization management, and appeals processing while ensuring compliance with regulatory, clinical, and organizational standards. The Director will develop and optimize workflows, policies, and performance measures to drive operational excellence and ensure that prior authorization services deliver superior clinical quality and member satisfaction.

As a key member of the Clinical Service/ Care Management leadership team, this individual will also partner cross-functionally with internal departments to advance efficiency, compliance, and innovation within Empi Rx Health’s utilization management framework.

Key Responsibilities

• Lead and mentor a team of Prior Authorization Pharmacists and Technicians to deliver efficient, compliant, and high-quality clinical review services.
• Conduct performance evaluations, provide developmental feedback, and promote a collaborative, positive team culture.
• Partner with the Vice President of Clinical Services to design and implement strategies that enhance prior authorization effectiveness and scalability.

• Develop, implement, and maintain standard operating procedures (SOPs) and policies that comply with federal, state, and PBM regulations.
• Educate staff on changes in healthcare policy, pharmacy regulations, and Empi Rx Health internal procedures.
• Oversee clinical audits, ensure documentation accuracy, and lead corrective action initiatives as needed.
• Maintain high-quality performance by auditing cases for accuracy, completeness, and adherence to review guidelines.

• Monitor and analyze prior authorization performance metrics, turnaround times, and cost-savings impact.
• Develop and deliver regular operational and performance reports for internal leadership and external stakeholders.
• Leverage internal platforms (e.g., DOMO, Salesforce, Power BI) for workflow monitoring, trend analysis, and staff productivity tracking.
• Identify process inefficiencies and implement continuous quality improvement initiatives to streamline workflows and enhance member experiences.

• Partner with other Empi Rx Health departments (e.g., Client Management, Population Health, Analytics, and IT) to align strategies and processes that support clinical and operational goals.
• Provide clinical guidance and operational insights in support of client implementations, escalations, and renewals.
• Collaborate with formulary management and clinical programs teams to ensure integration of prior authorization policies and clinical initiatives.

• Stay informed of drug pipeline developments, clinical guidelines, and regulatory updates through continuous education and professional memberships.
• Use external resources such as IPD, Up To Date , and Medi-Span to support evidence-based clinical decision-making.
• Support staff training initiatives…