Judi Health
Healthcare
Manager,UtilizationManagement-Commercial
Neural analysis suggests this role is
optimal for Mid candidates.
“Manager, Utilization Management - Commercial at Judi Health. Skills: utilization management, prior authorization, leadership. 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.”
Industry & Context.
occasional on‑call responsibilities, flexibility to work outside of regular business hours based on business needs
What They're Looking For.
Must Have
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
Nice to Have
3+ years of leadership experience preferred, Experience with multiple lines of business including Commercial and Medicare Part D preferred
What You'll Do.
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
Oversee the UM quality management process to ensure compliance with state
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.
Prior Authorization on other responsibilities
and initiatives as needed.
Perform day to day clinical pharmacy functions including prior authorization and appeal reviews
and inbound and outbound member and provider education calls.
How You'll Work.
Team & Collaboration
Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed.
Communication Scope
written communication; oral presentation skills
Full Job Description
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
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