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Utilization Management Relations Pharmacist
Position Overview:
The Utilization Management Relations Pharmacist is a client-facing role responsible for managing clients’ Utilization Management questions as it pertains to complex workflows. They will act as the liaison between Capital Rx’s internal clinical and account management teams serving as the subject matter expert for anything UM-related. This position offers candidates a career growth opportunity while developing knowledge around UM workflows and technology.
Position Responsibilities:
- Manage inquiries and escalations from internal and external stakeholders related to Prior Authorization (PA)/Utilization Management (UM) processes and workflows across multiple lines of business, including but not limited to Medicare, Commercial, and Exchange
- Develop deep knowledge of Capital Rx PA workflow and policies, working closely with clinical PA and PA Tool Product teams
- Work collaboratively across the organization, create and maintain PA workflow resources to serve as reference for Clinical Account Management teams and clients
- Manage client deliverables and discussions in an efficient and timely manner including tracking of client needs/questions and working internally to resolve issues and answer client specific questions
- Provide account teams and clients comprehensive insight of regulatory requirements that apply to prior authorization operations (i.e., turnaround times) across all lines of business
- Support client level training and inquiries for Capital Rx’s internal PA Tool (PAT)
- Support implementation of new plans by acting as liaison with PA team to determine delegated functions, workflow, and expectations
- Assist with additional clinical projects assigned as needed, pending business needs
- Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance
Required Qualifications:
- Doctor of Pharmacy (PharmD) degree, required from an accredited institution
- Current, unrestricted registered pharmacist license(s)
- 3+ years of Clinical Utilization Management operations experience, required
- Prior authorization experience, required
- Project management experience, preferred
- Experience working in a health plan setting, preferred
- Deep understanding of PA workflows, regulations, and terminology
- Experience with Medicare Part D and Part B utilization management, preferred
- Ability to prioritize, quickly assess, and manage multiple tasks and adapt to continually changing situations
- Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables
- Ability to work independently with minimal supervision, stay productive in remote, high-volume work environment
- Proficient in Microsoft Office suite
- Ability to balance multiple complex projects simultaneously
- Exceptional written and verbal communication skills
- Extremely flexible, highly organized, and able to shift priorities easily
- Ability to travel and present to small and large groups
This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
Salary Range
$125,000 - $145,000 USD
About Capital Rx
Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi®, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.
Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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