Manager, Utilization Management - Commercial

Capital Rx is a next generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers, unions, and government entities. Determined to transform an outdated model, Capital Rx's mission is to change the way prescription benefits are priced and administered in the US, unlocking enduring social change. Through our platform approach, Capital Rx delivers data-driven insights and actionable strategies that reduce costs, while improving patient outcomes. Our commitment to innovation, technology, and service is the reason why Capital Rx is among the fastest-growing PBMs in the country.

Position Responsibilities:

• 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 oncall responsibilities and the flexibility to work outside of regular business hours based on business needs.

Required Qualifications:

• 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

This range represents the low and high end of the anticipated base salary range for the NY - based position. The actual base salary will depend on several factors such as: experience, knowledge, and skills, and if the location of the job changes.