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Utilization Management Pharmacist (temp-to-hire)
Position Summary:
The Utilization Management Pharmacist plays a vital role in promoting safe, effective, and appropriate medication use. This position is responsible for reviewing prior authorization requests, supporting clinical programs, and providing expert guidance to members, providers, and pharmacies. The role combines clinical decision-making with a strong focus on service excellence in a fast-paced, collaborative environment.
Position Responsibilities:
Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria.
Ensure compliance with federal, state, and internal regulations across Commercial, Exchange, Medicare, and Medicaid plans.
Accurately document clinical decisions and maintain thorough records in accordance with regulatory and accreditation (URAC/NCQA) utilization review standards.
Provide clear, empathetic support to members, prescribers, and pharmacies by responding to clinical inquiries via phone, demonstrating professionalism, active listening, and a patient-centered approach.
Stay current with clinical prescribing guidelines, internal policies, and regulatory changes, and apply them to daily responsibilities.
Follow all internal procedures, job aids, and HIPAA guidelines to protect patient privacy and data security.
Identify and report potential fraud, waste, and abuse.
Support training and development of new and existing team members as needed.
Assist leadership with special projects, process improvements, and operational initiatives
Minimum Qualifications:
Minimum of 6 months to a year of prior authorization or utilization management experience
Active, unrestricted, pharmacist license
Bachelor’s or Doctor of Pharmacy degree
Minimum of 2 years of pharmacy practice experience
Experience in managed care or pharmacy benefit management (PBM)
Strong communication, writing, and organizational skills
Ability to manage multiple priorities in a high-volume, metric-driven environment
Availability to work after hours, weekends, and holidays on a rotating schedule
Preferred Qualifications:
Call center experience
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.
Senior Legal Counsel – Medicare, Healthcare Regulatory & Contracting
Location: Hybrid (at least 3 days per week in our NYC, Denver, or Charlotte offices)
Position Summary
We are seeking an experienced and business-oriented healthcare attorney to join our Legal team. This role will serve as a strategic legal advisor to senior leadership and business partners, providing legal support across Medicare Part D, healthcare regulatory compliance, contracting, and operational initiatives.
The successful candidate will have deep experience with Medicare, health insurance and healthcare laws, substantial healthcare contracting expertise, and the ability to provide practical legal advice that balances regulatory requirements with business objectives. This attorney will play a key role in supporting a rapidly growing healthcare organization operating in a highly regulated environment.
Position Responsibilities:
Medicare & Healthcare Regulatory Compliance/Contracting
Provide legal advice regarding Medicare Part D, health insurance and other federal healthcare program requirements.
Counsel business teams on CMS regulations, guidance, audits, reporting obligations, and regulatory enforcement matters.
Monitor and interpret changes in healthcare laws and regulations and advise leadership regarding operational impacts.
Support regulatory change management initiatives and implementation of new legal requirements.
Advise on regulatory risks associated with business operations, products, and strategic initiatives.
Assist with government audits, investigations, corrective action plans, and responses to regulatory inquiries.
Draft, review, negotiate, and advise on a broad range of healthcare and commercial agreements, including:
Rebate and delegation agreements
Client agreements
Network and managed care contracts
Develop contracting standards, templates, negotiation playbooks, and risk management processes.
Partner with procurement, operations, compliance, and business teams to facilitate efficient contract review and execution.
Support vendor selection, due diligence, onboarding, and ongoing oversight activities.
Provide legal guidance on:
False Claims Act
Anti-Kickback Statute
Stark Law
Medicare and Medicaid requirements
State insurance and healthcare regulations
Support compliance investigations, policy development, training initiatives, and operational audits.
Provide practical, solution-oriented legal guidance aligned with business objectives.
Identify legal risks and develop creative, operationally feasible solutions.
Support corporate growth initiatives, product development, and strategic transactions as needed.
Required Qualifications
Juris Doctor (J.D.) from an accredited law school.
Active license and good standing in at least one U.S. state.
8+ years of legal experience in a law firm, healthcare organization, health plan, PBM, managed care organization, or combination thereof.
Significant experience with Medicare Part D regulatory requirements.
Extensive healthcare contracting experience, including complex commercial and vendor agreements.
Strong knowledge of federal and state healthcare laws and regulations.
Experience advising cross-functional business teams in a fast-paced environment.
Excellent drafting, negotiation, analytical, and communication skills.
Demonstrated ability to manage multiple priorities independently.
Preferred Qualifications:
Experience supporting Medicare Advantage plans, PBMs, health plans, TPAs, or managed care organizations.
Experience with CMS audits, corrective action plans, and regulatory examinations.
Knowledge of delegated entity and FDR oversight requirements.
Experience with provider contracting and network management.
Experience with healthcare technology, data privacy, and digital health products.
Familiarity with Medicaid and commercial health plan regulations.
Experience supporting mergers, acquisitions, and strategic healthcare transactions.
Critical Competencies:
Medicare and CMS regulatory expertise
Healthcare and vendor contracting
Healthcare compliance and risk management
Business-oriented legal judgment
Practical problem-solving
Project management and organizational skills
Collaboration across legal, compliance, operations, and business teams
Why This Role Matters
This attorney will serve as a key member of the Legal organization, helping the company scale responsibly while navigating complex Medicare, healthcare regulatory, and contracting obligations. The role offers the opportunity to shape legal strategy, influence business decisions, and build processes that support continued growth and operational excellence.
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