Lead Clinical Authorization and Appeals Specialist

PANTHERx is the nation’s largest rare disease pharmacy, dedicated to providing uncompromising quality and superior health outcomes for patients living with rare and devastating diseases. We seek inspired, compassionate problem solvers who produce high-quality work and thrive in a dynamic healthcare environment.

About the role

The Lead Clinical Authorization and Appeals Specialist leads the development, management, and oversight of the clinical authorization and appeal process within a RxARECARE team. This role supports the Lead Pharmacist, Supervisor, and/or Manager of RxARECARE Program Operations by ensuring daily task completion, mentoring team members, and driving process improvement.

Responsibilities

• Participates in program-specific process changes and provides training for new process updates.
• Schedules and distributes assigned responsibilities to team members daily.
• Ensures all prior authorization and appeal tasks are completed daily.
• Evaluates and acts on daily reports regarding prior authorizations and appeals to exceed partner expectations.
• Ensures manufacturer business rules are followed for prior authorization and appeal processes.
• Supports team staffing efforts as necessary.
• Possesses a broad and deep understanding of assigned disease states, products, and clinical programs.
• Collaborates closely with program management team members and external stakeholders.
• Coordinates with other Leads and PANTHERx departments on escalations, as needed.
• Assists RxARECARE Supervisor with annual performance evaluations.
• Demonstrates appropriate judgment to make independent clinical decisions.
• Fosters teamwork by encouraging collaboration at all levels within the organization.
• Handles additional projects and activities as assigned.

Requirements

• Associate degree or bachelor’s degree from an accredited nursing school as a Registered Nurse (RN).
• Minimum of two (2) years of direct patient care experience in a community health or patient care setting.
• Strong writing and grammar skills.
• Strong organizational skills and proficiency in Microsoft Office and Windows.
• Demonstrated ability to work independently and meet goals.

Preferred Qualifications

• Minimum of five (5) years as a practicing, licensed Registered Nurse (RN).
• Minimum of two (2) years of specialty pharmacy experience.

Work Environment

This position operates in a home or professional office environment and routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines.

Physical Demands

While performing the duties of this job, the employee is regularly required to sit, see, talk, or hear. The employee frequently stands, walks, uses hands and fingers to handle or feel, and reaches with hands and arms. Visual acuity is necessary for reading and working with data. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Benefits

• Hybrid, remote, and flexible on-site work schedules (based on position).
• Medical, dental, and vision coverage.
• Health savings and flexible spending accounts.
• 401K with employer matching.
• Employer-paid life insurance and short/long-term disability coverage.
• Employee Assistance Program.
• Generous paid time off for full-time employees; limited paid time off for part-time employees.
• Paid holidays.