Manager, Utilization Management – Commercial
Capital Rx
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $140,000 - $150,000 per year
About the role
- Lead and nurture a dynamic team of clinical pharmacists and technicians dedicated to the prior authorization and appeals process.
- Create and uphold robust policies and procedures for utilization management review.
- Utilize available data to optimize prior authorization staffing and streamline workflow.
- Actively participate in goal setting and regularly evaluate the performance of the PA team.
- Respond to requests for information (RFI) and requests for proposal (RFP) regarding prior authorization processes.
- Generate and deliver comprehensive reports on prior authorization metrics to both internal and external stakeholders.
- Manage contracts with external Independent Review Organizations and clinical resource vendors
- Supervise the UM quality management process to ensure compliance with state, federal, and regulatory guidelines.
- Participates in the quality improvement committee and supports quality improvement projects as required by URAC.
- Oversee clinical criteria and decision tree creation and maintenance.
- Lead the recruitment and onboarding process for pharmacists and technicians.
- Support the training and growth of both new and existing staff members in adherence to proper procedures.
- Investigate and resolve escalated issues from clients and clinical partners as needed.
- Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed.
- Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
- Schedule requires working Monday through Friday with occasional on‑call responsibilities and the flexibility to work outside of regular business hours based on business needs.
Requirements
- Active, unrestricted, pharmacist license required
- Bachelor of Pharmacy or Doctorate of Pharmacy Degree required
- 4+ years of prior authorization experience at a PBM or health plan
- 3+ years of leadership experience preferred
- Experience with multiple lines of business including Commercial and Medicare Part D preferred
- Exhibit strong written communication and oral presentation skills
- Proficient in Microsoft office Suite with an emphasis on PowerPoint and Excel
- Ability to work in a fast-paced environment with shifting priorities
- Attention to detail & commitment to delivering high-quality work.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
prior authorizationutilization managementclinical pharmacy functionsappeal reviewsoverride requestsdata analysisquality managementcontract managementreport generationclinical criteria development
Soft Skills
leadershipcommunicationteam managementproblem-solvingattention to detailgoal settingperformance evaluationtraining and developmentflexibilityorganizational skills
Certifications
pharmacist license