Current openings at Judi Health

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.

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