Rx Prior Authorization - Team Lead

Position Summary

The Rx Prior Authorization Team Lead (L3) serves as a subject matter expert and quality lead within the enGen Global Prior Rx Authorization team. This role encompasses all L1 responsibilities while also managing complex PA cases, overseeing quality assurance, providing guidance to L1 associates, and acting as a primary liaison with the West team for process improvements and training

L3 associates ensure adherence to clinical rationale, regulatory compliance, and efficiency in the PA process

Work Location: Chennai

Core Responsibilities

• Monitor and manage the AHN Pharmacy Prior Authorization workqueue in Epic, ensuring adherence to prioritization guidelines
• Initiate Prospective and Retrospective PA requests within Epic, accurately populating all required patient and medication details
• Identify PA statuses and perform routine follow-up actions as per protocol
• Accurately create and update notes/encounters in Epic to document PA-related activities, including chart review, communications, and verdict details
• Upload external faxes or documents into the patient's chart in Epic, saving initial files securely as needed
• Manually enter authorization details (number, start/end dates) into Epic for authorizations received via external means
• Communicate with pharmacies or other entities via fax or secure electronic messaging as per defined processes including direct voice calls
• Handle complex or escalated PA requests, including those involving unique patient circumstances, non-formulary medications, quantity limits, step therapy, and tier exceptions, applying appropriate clinical rationale
• Assist in routing PA denials to the West for appeals, and compile necessary initial documentation for the appeals process
• Conduct regular quality audits of L1 associates' work, ensuring accuracy, completeness, and adherence to documentation standards, regulatory guidelines, and AHN policies
• Identify common errors, knowledge gaps, and areas for process improvement therein
• Develop and deliver targeted training sessions and coaching for L1 associates on complex PA scenarios, system updates, and quality improvement initiatives
• Serve as the primary internal resource for L1 associates seeking clarification on workflows, medical terminology, or system navigation
• Function as a direct point of contact for the West team regarding operational questions, process discrepancies, and complex case discussions
• Participate in joint West-East meetings to discuss workload, challenges, process improvements, and performance metrics
• Liaise with West team pharmacists for evaluation of complex PA denials, formulary alternatives, and appeals that require clinical oversight or direct provider/payer interaction
• Contribute to updating or creating Standard Operating Procedures (SOPs) and job aids based on West team input and best practices
• Manage and maintain data for reporting needs

Education

Advanced degree in Pharmacy or medical field (e.g., M.Pharm, B.Pharm with extensive relevant experience, or equivalent medical qualification from an accredited institution in India, demonstrating strong understanding of medical concepts, pharmacology, and clinical decision-making)

Experience

5+ years of progressive experience in healthcare administration, pharmacy services, or prior authorization processing, with at least 1-2 years in a senior or quality assurance role. Prior experience with U.S. healthcare operations or Epic systems preferred

Skills

• Knowledge of medical terminology, pharmacology, and common therapeutic areas relevant to prior authorizations
• Demonstrated ability to perform detailed medical chart review and synthesize clinical information
• Exceptional analytical and critical thinking skills, with the ability to manage complex cases independently
• Strong leadership and mentoring capabilities, with experience in training and guiding team members
• Superior written and verbal English communication skills

Availability

Must be able to work in shifts that overlap for a few hours with U.S. Eastern Time Zone

About enGen Global

enGen Global is at the forefront of healthcare's Global Capability Centers (GCC) in India, dedicated to creating powerful and innovative solutions that have a transformative impact on lives. The company's cutting-edge solutions empower healthcare partners to manage their operations through comprehensive, proven platforms, enabling them to focus on their core strengths – delivering positive experiences to healthcare consumers and ensuring excellence in service and care. enGen Global’s wide-ranging solutions encompass IT Health Plan and IT Health Consumer Solutions, Application and Platform Management, Enterprise Solutions and Transformations, Development, Testing, Diversified Business Solutions, and Business Process Services. Operating within India's thriving landscape of emerging GCCs, enGen Global boasts a robust partner ecosystem, incorporating best-in-class engineering processes, tools, solution accelerators, talent, research, and co-innovation capabilities.

We believe our people are our greatest asset. The diverse perspectives that our talent bring to our global workforce are foundational to our success. enGen Global is proud to be an equal opportunity employer, committed to fostering a culture of integrity, diversity, and inclusion. We do not discriminate based on any protected characteristic.