Manager, Utilization Management - Commercial (Medtech)

TL;DR

Manager, Utilization Management - Commercial (Medtech): Leading a team of clinical pharmacists and technicians to manage prior authorizations and appeals with an accent on regulatory compliance and workflow optimization. Focus on upholding utilization management policies, streamlining PA processes, and ensuring adherence to state and federal guidelines.

Location: Remote (Must be based in New York, US)

Salary: $155,000 - $170,000 USD

Company

Enterprise health technology company providing a comprehensive suite of health benefit management and pharmacy benefit management (PBM) solutions through its proprietary Enterprise Health Platform.

What you will do

• Lead and nurture a team of clinical pharmacists and technicians dedicated to prior authorization and appeals processes.
• Create and uphold robust policies and procedures for utilization management review.
• Utilize data to optimize staffing and streamline PA workflows.
• Manage contracts with external Independent Review Organizations and clinical resource vendors.
• Oversee the UM quality management process to ensure compliance with state, federal, and URAC guidelines.
• Perform day-to-day clinical pharmacy functions, including appeal reviews and provider education calls.

Requirements

• Active, unrestricted pharmacist license.
• Bachelor of Pharmacy or Doctorate of Pharmacy Degree.
• 4+ years of prior authorization experience at a PBM or health plan.
• Must be based in New York.
• Proficiency in Microsoft Office Suite, specifically Excel and PowerPoint.
• Strong written communication and oral presentation skills.

Nice to have

• 3+ years of leadership experience.
• Experience with Commercial and Medicare Part D lines of business.

Culture & Benefits

• Opportunity to work with a fast-growing PBM transforming healthcare infrastructure in the US.
• Dynamic environment focused on data-driven insights and improving patient outcomes.
• Commitment to a diverse workplace and equal employment opportunities.