Manager, Utilization Management - Commercial

About Judi Health

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers,
• Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and
• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform.

Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health.

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 Determined to transform an outdated model, Capital Rx’s mission is to change the way prescription benefits are priced and administered in the US, unlocking enduring social change.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 on‑call 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.

All employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance. 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.

Judi Health 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. 

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy.