AffirmedRx, a Public Benefit Corporation

Director, Utilization Management

AffirmedRx, a Public Benefit Corporation

full-time

Posted on:

Location Type: Remote

Location: Kentucky • United States

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Job Level

Lead

About the role

  • Define and evolve the organization’s utilization management strategy, ensuring alignment with client benefit designs, affordability goals, regulatory requirements, and AffirmedRx’s transparent PBM model
  • Serve as a clinical and operational thought partner to executive leadership, advising on UM tradeoffs related to access, member experience, cost management, and regulatory risk
  • Translate client-specific goals and contractual requirements into tailored UM programs, guardrails, and workflows
  • Develop a multi-year UM roadmap, including technology enablement, automation, and electronic PA integration
  • Own end-to-end PA and UM operations, including intake, clinical review, peer-to-peer processes, determinations, and communications
  • Establish and monitor operational KPIs (turnaround times, quality accuracy, production metrics, escalation rates) and drive corrective actions
  • Optimize UM workflows to ensure scalability, audit readiness, and seamless integration with client and provider systems
  • Lead process improvement initiatives leveraging data, root cause analysis, and automation
  • Ensure UM decisions are evidence-based, clinically sound, and aligned with plan design and coverage criteria
  • Oversee peer-to-peer review processes and ensure consistent, high-quality clinical determinations
  • Review and assess clinical literature to support UM criteria, policy updates, and provide guidance
  • Ensure accuracy and consistency of denial rationales, clinical communications, and member/provider-facing materials
  • Partner with finance and clinical strategy teams to assess the financial impact of UM programs, including cost avoidance, utilization trends, and operational efficiency
  • Ensure UM strategies balance affordability with access, minimizing inappropriate utilization while avoiding unnecessary member or provider friction
  • Support budgeting, forecasting, and resource planning for UM operations
  • Serve as an escalation point for complex or high-impact client UM issues, delivering timely, thoughtful, and defensible resolutions
  • Support client-facing discussions related to UM strategy, program performance, and regulatory compliance
  • Partner with Client Success and Sales teams to support implementations, renewals, and ongoing client satisfaction
  • Ensure ongoing compliance with URAC, NCQA, and applicable regulatory requirements
  • Maintain audit readiness and lead UM-related accreditation activities, assessments, and corrective action plans
  • Stay current on evolving UM regulations, industry standards, and best practices, proactively adjusting programs as needed

Requirements

  • Bachelor's degree in Pharmacy
  • Advanced degree (PharmD, MSN, MPH, MBA) preferred
  • 10+ years of experience in prior authorization operations, clinical services or related roles, with at least 5 years in a leadership position
  • 3+ years of experience in pharmacy or pharmacy benefit management (PBM) preferred
  • Deep understanding of PA processes, staffing models, and clinical workflows
  • Knowledge of regulatory and accreditation requirements, particularly URAC and NCQA standards
  • Excellent analytical, organizational, and problem-solving skills
  • Ability to work collaboratively with cross-functional teams
  • Willingness and ability to travel (10%-20%)
Benefits
  • Competitive compensation, including health, dental, vision and other benefits
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
utilization managementprior authorizationclinical reviewdata analysisprocess improvementautomationelectronic PA integrationoperational KPIsclinical workflowsbudgeting
Soft Skills
analytical skillsorganizational skillsproblem-solving skillscollaborationleadershipcommunicationstrategic thinkingclient-facing discussionsadaptabilitythought partnership
Certifications
Pharmacy degreePharmDMSNMPHMBAURAC complianceNCQA compliance