Navitus

Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other._____________________________________________________________________________________________________________________________________________________________________________________________________________. Current associates must use SSO login option at https://employees-navitus.icims.com/ to be considered for internal opportunities.

USD $120,525.00 - USD $150,656.00 /Yr.

M-F 8am to 5pm, CT

ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

Navitus Health Solutions is seeking a Grievance and Appeals Manager to join our team!

 

The Manager of the Grievance and Appeals (G&A) Department is responsible for the day-to-day leadership/support of the G&A staff. The Manager will act as a subject matter expert (SME) for implementation teams, government program reporting, client team inquiries, call center, prior authorization, and drug information teams The G&A Manager will be responsible for all applicable departmental policies and procedures, any corrective action required as a result of internal/external audit, responding to inquiries related to G&A processes for sales and implementation. The G&A Manager will oversee all operational duties performed by the G&A team, as well as all clinical determinations made by the clinical appeal staff. The Manager, G&A serves as a point of escalation and expertise for both internal and external customers. Independent review vendors (IRO/IRE) will use the G&A Manager as a central point of contact for any communication between these organizations. In addition to staff support, monitoring and escalations, the Manager, G&A is responsible for facilitating and maintaining an environment that fosters process improvement by maintaining relationships with external review organizations, maintaining department resources, G&A reporting, tracking, trending and forecasting summaries, department representation in meetings, prepare and present for audits and will serve as a technology SME for Navitus system(s) used by the G&A department. The Manager, G&A will ensure department metrics are met through monitoring of staff performance using a multitude of software applications including Calibrio, Adobe, Visio, Excel, Crystal, and all MS Office applications.

 

Is this you? Find out more below!

How do I make an impact on my team? 

• Ensure daily workloads standards and metrics are met
• Responsible for day-to-day leadership/support of department staff
• Facilitate training/development needs for individuals and department
• Implement and maintain G/A technology resources to meet the needs of the business
• Review and prepare reports which monitor performance guarantees to/from Navitus Health Solutions
• Oversee clinical determinations made by departmental clinical staff and responsible for evaluating trends and proposing utilization management changes based on IRO/IRE determinations
• Manage and maintain resources that support G/A staff
• Act as the first point of contact with vendors, clients and internal departments
• Other duties as assigned

What our team expects from you?

• A minimum of a Bachelors Degree in Pharmacy or Pharm D. Current, unrestricted, licensure as an RPh in home state or the ability to gain licensure within 4 months of employment is required
• 3-5 years of managed care and/or insurance background preferred in addition to a strong knowledge of CMS coverage determination and redetermination processes
• Experience with CMS and/or NCQA audits strongly desired
• 1-3 years of leadership experience preferred
• Knowledge of the PBM industry, formulary management, pharmacy claims and managed care principles and practices is desired
• Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) required
• Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
• Requires attention to details in order to assure projects are clinically, editorially, and systems accurate and can be operationalized
• Proficiency in MS Word, Excel, Power Point including tables, charts and figures preferred
• 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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