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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.
Formulary Operations Pharmacist
Location: Hybrid (Local to New York, New York; Denver, Colorado; or Charlotte, North Carolina area)
Position Summary:
The Formulary Operations Pharmacist – Medicare is responsible for providing operational support for the evaluation, implementation, and maintenance of Medicare Part D formularies and utilization management. This individual supports creation and maintenance of formulary and utilization management lists, preparation of CMS formulary files and member formulary drug lists, preparation and review of updates for implementation, and other formulary and utilization management related tasks and processes. The role requires strong cross functional collaboration and communication skills, and an understanding of Medicare Part D formulary management processes and related CMS rules and regulations. The position also provides support to non-Medicare formulary management tasks as opportunities arise.
Position Responsibilities:
Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelines
Supports the development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug lists
Leads and supports the preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, and utilization management criteria
Expanded scope of responsibilities across other non-Medicare business lines when needed, driving alignment, operational excellence, and strategic execution across diverse functions
Evaluate drugs and drug classes, to provide formulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalize
Evaluates the appropriateness of and operationalizes custom client formulary and benefit change requests within the formulary and adjudication platform
Creates customized marketing materials, including but not limited to member formulary drug lists, utilization management criteria documentation, and web-based look up tools
Supports the comprehensive testing of client formulary and benefit elections
Supports custom formulary client trade and rebate strategy evaluation
Identifies opportunities for automation and collaborates with Analytics to streamline processes and workflows
Analyzes pharmacy cost of care and clinical updates for the development of formulary management programs and utilization management edits
Provides clinical support to operational teams and clients during implementations
Serves as the clinical operations liaison to assist with ad-hoc sales requests and strategic communications for clients to provide expert insights from a clinical perspective
Quality assurance checks of Formulary Specialist activities, with emphasis on actions impacting adjudication of claims for accuracy
Provides cross functional support for claims troubleshooting within the adjudication platform
Monitors and analyzes regulatory and legislative requirements for Medicare
Leads and supports timely submission of all required reporting to State and Federal regulators, such as required formulary submissions to Health Plan Management System (HPMS)
Supports the development of project plans to meet new CMS requirements, and supports cross functional teams with implementation of programs to meet requirements
Leads formulary change processes within URAC/NCQA/CMS guidelines
Supports Pharmacy and Therapeutics (P&T) committee items, as required
Maintains and updates the Rx pharmaceutical pipeline, development of monthly newsletters, and other client communications as needed
Develops clinical criteria for review as needed
Supports CMS Program Audits as a formulary administration subject matter expert and provide necessary input of information to complete any auditor requested deliverables, including but not limited to root cause analysis, beneficiary impact analysis, and corrective action plans
Supports Quality Improvement projects, clinical value projects, and continuous improvement initiatives, as needed
Supports Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed
Support general business needs and operations, as needed
Supports review of new regulatory guidance and regulations that impact formulary administration and provide guidance to internal and external stakeholders for compliant action
Maintains compliance with all regulatory and organizational deadlines
Responsible for adherence to the Judi Rx Code of Conduct including reporting of noncompliance
Performs other duties and responsibilities as needed
Minimum Qualifications:
Doctor of Pharmacy (PharmD) Degree from an accredited institution
Current, unrestricted registered pharmacist license(s)
Residency/fellowship preferred
2+ years of Medicare formulary experience working for a health plan or PBM
Knowledge of formulary development and maintenance processes
Knowledge of highly managed specialty medications/strategy
Knowledge of rebate and financial implications of formulary strategies
Experience working with large datasets required
Ability to independently identify, research, and resolve issues
Ability to balance multiple complex projects simultaneously
Ability to work extended hours, weekends, and holidays consistent with industry demands
Exceptional written and verbal communication skills
Extremely flexible, highly organized, and able to shift priorities easily
Attention to detail & commitment to delivering high quality work product
Proficient in Microsoft office suite with stong emphasis in Microsoft Excel required
#LI-LC1
Clinical Programs Case Management Specialist
Position Summary:
The Clinical Programs Case Management Specialist is responsible for supporting Judi Health’s site-of-care optimization program by conducting outreach to members, prescribers, and infusion providers to facilitate a seamless transition of infusion services when appropriate. This role serves as a key liaison with external vendors and internal stakeholders to ensure programs are executed effectively and efficiently, stakeholders remain informed, and members receive timely, high-quality support.
Position Responsibilities:
Clinical Programs Administration
Own the administrative processes related to Judi Rx’s site-of-care optimization program referrals, including conducting and coordinating outreach to members, prescribers, pharmacies, and other healthcare stakeholders.
Educate members on infusion therapy options, site-of-care alternatives, benefit considerations, and available support resources to promote informed healthcare decisions.
Coordinate with members, prescriber offices, patient coordinators, and care navigators to facilitate referrals, support continuity of care, and provide status updates throughout the referral process.
Serve as a liaison between internal teams, providers, and external partners to address questions, resolve issues, and support timely service delivery.
Deliver compassionate, professional, and customer-focused support while maintaining a positive member and provider experience.
Accurately document outreach attempts, case activities, interventions, outcomes, and follow-up actions in applicable systems.
Program Coordination & Case Management
Manage assigned case workloads, outreach queues, and pending activities to support timely case resolution and continuity of care.
Track and monitor referral progress, escalations, and program-related activities to ensure adherence to established service levels and workflows.
Maintain program resources, including drug lists, workflow documentation, and operational materials through routine reviews and updates.
Identify, document, and escalate issues or barriers impacting member access, provider engagement, or program effectiveness.
Support departmental initiatives and perform additional duties as assigned.
Collaboration & Stakeholder Engagement
Partner with clinical, operational, account management, and business teams to support program implementation, execution, and ongoing success.
Collaborate with internal and external stakeholders to ensure effective communication, care coordination, and issue resolution.
Support reporting activities, claims monitoring, opportunity analysis, and stakeholder communications related to clinical program performance and outcomes.
Participate in cross-functional meetings and provide program insights, feedback, and recommendations to support business objectives.
Quality Improvement & Operational Excellence
Identify trends, workflow inefficiencies, and opportunities for process improvement to enhance program performance, operational efficiency, and member outcomes.
Contribute to the development and refinement of workflows, job aids, training materials, and standard operating procedures.
Support quality assurance activities and continuous improvement initiatives designed to strengthen program effectiveness and service delivery.
Compliance & Regulatory Requirements
Maintain compliance with all applicable federal, state, local, contractual, and organizational requirements.
Adhere to HIPAA regulations, internal policies, standard operating procedures, and confidentiality requirements in the performance of all responsibilities.
Remain current on clinical program requirements, regulatory updates, organizational communications, and process changes, applying updates appropriately to daily work activities.
Demonstrate commitment to ethical business practices, data integrity, and protection of member information.
Minimum Qualifications:
Experience in medical case management, patient care, or healthcare support roles such as hospital pharmacy technician, CNA, RN, outpatient technician, or similar clinical positions.
Experience working with electronic medical records (EMRs), patient assistance programs (PAPs), healthcare documentation systems, and prescriber office workflows.
Minimum of 3 years of experience in a clinical setting, pharmacy benefit management (PBM), health plan, or related healthcare environment.
At least 1 year of customer service experience with a demonstrated commitment to delivering exceptional service through active listening, relationship building, and effective written and verbal communication.
Ability to manage multiple priorities and complex projects simultaneously while working independently with minimal supervision.
Reliable high-speed internet service via DSL, cable, or fiber with a wired connection to the work device (Wi-Fi not permitted). Minimum internet speed of 940 Mbps (1 Gigabit) required.
Preferred Qualifications:
Proficient in Microsoft Office Suite applications with emphasis on Microsoft Excel and PowerPoint
Experience with Confluence, Jira, Tableau, Salesforce
Highly detail-oriented and analytical
Bilingual- Spanish preferred
Experience with infusion proviers, vendor relations, and site of care initiatives
Experience working with pharmacy and medical claims and medical billing
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