Clinical Pharmacist- Utilization Management

Rightway Healthcare; New York (NY); On-site; USD 120,000 - 125,000; Full time

Job summary

Rightway Healthcare is hiring a Clinical Pharmacist, Utilization Management to join our PBM Clinical Operations team in New York. You will review UM requests, ensure compliant PBM service delivery, and coordinate with pharmacists, technicians, and medical directors across UM activities.

The role emphasizes evidence-based decision making, collaboration with prescribers, and participation in quality and P&T processes.

Qualifications

• Pharmacy degree required; PharmD preferred.
• 1 year coordinating medication selection with prescribers.
• Preferred 1–3+ years in managed care / PBM prior authorization.
• Licensed pharmacist in good standing; multi-state licensure possible.
• Available to work 40 hours per week with possible evenings/weekends.
• Detail-oriented, analytical, empathetic with strong listening skills.
• Ability to influence others even without direct reporting lines.

Responsibilities

• Review utilization management requests for coverage that are clinically appropriate and cost effective.
• Continuously review UM processes to ensure compliant delivery of PBM services.
• Coordinate with Pharmacy technicians, Pharmacists, and Medical Directors on UM activities.
• Ensure cases are reviewed in accordance with State and Federal guidelines including turnaround time requirements.
• Discuss clinical strategy and decision rationale with prescribers as needed.
• Participate in the quality review and inter-rater reliability processes.
• Support P&T processes including the development of therapeutic class/drug monographs as needed.
• Research and develop therapy-specific clinical policies and UM programs such as Prior Authorization, Step Therapy, Quantity Limit, and Coverage Determination.

Skills

Pharmacy benefit knowledge

Problem-solving

Change management

Communication skills

Project leadership

Education

Pharmacy degree required

PharmD preferred

Job description

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ABOUT THE ROLE:

Our PBM goal is to help clients better manage pharmacy spend to make drugs more affordable for their employees and dependents. Rightway is responsible for designing, building, and operating a new-to-the-world PBM model based on our core tenets: fairness & transparency, unlocking the supply chain, supporting the physician-patient relationship, and utilizing navigation to empower consumers. This role will assist UM leadership in delivering on our UM strategy and actively work UM cases.

The Clinical Pharmacist, Utilization Management is a member of the Rightway PBM Clinical Operations team. Our pharmacy benefit management (PBM) offering represents an important growth area for Rightway. Helping clients better manage pharmacy spend to make drugs more affordable for their employees and dependents is critical to their business sustainability. RightwayRx is responsible for designing, building and operating a new-to-the-world PBM model base on our core tenets: fairness & transparency, unlocking the supply chain, supporting the physician-patient relationship, and utilizing navigation to empower consumers

WHAT YOU’LL DO:

• Support all lines of business via reviewing utilization management requests for coverage that are clinically appropriate and cost effective
• Continual review of UM operational processes to ensure effective and compliant delivery of PBM services to our clients.
• Coordinate with Pharmacy technicians, Pharmacists, and/or Medical Directors on UM activities
• Ensure cases are reviewed in accordance with State and/or Federal guidelines including turnaround time requirements
• As needed, discuss clinical strategy and decision rationale with prescribers
• Participate in the quality review and inter-rater reliability processes
• Supports P&T process including the development of therapeutic class/drug monographs as needed
• Research and develop therapy-specific clinical policies and utilization management programs such as Prior Authorization, Step Therapy, Quantity Limit, and/or Coverage Determination programs
• Support Clinical Operations leadership and coordinate with Pharmacy Navigation team as needed

WHO YOU ARE:

• Education level: Pharmacy Degree Required, PharmD preferred.
• Work experience: 1 year experience coordinating medication selection with prescribers and their care teams. Preferred: 1-3+ years of managed care (PBM or health plan) prior authorization experience
• Pharmacist license in good standing in state of residence. Willingness to achieve and maintain licensure in multiple states (if needed)
• Available to work 40 hours/week. Core operating hours are weekdays within 8 am Eastern Time and 8 pm Eastern Time, but may be required to work evening and/or weekend shifts in the future as Rightway grows. On call approximately once every two months.
• Important characteristics of ideal candidate: Detail-oriented, intellectually and clinically curious, good listener, empathetic, ability to challenge status quo, values exemplar
• Specific skills needed for job: Great pharmacy benefit knowledge, effective & creative problem-solver, ability to prioritize and manage through change. Solid communication skills, ability to lead projects and influence others even without direct reporting line ownership

BASE SALARY: $120,000-125,000 annually, in addition to bonus and equity

Compensation offered will be determined by geographic location, experience, and qualifications.

CYBERSECURITY AWARENESS NOTICE

In response to ongoing and industry-wide fraudulent recruitment activities (i.e., job scams), Rightway wants to inform potential candidates that we will only contact them from the @ rightwayhealthcare.com email domain. We will never ask for bank details or deposits of any kind as a condition of employment.

ABOUT RIGHTWAY:

Rightway is on a mission to harmonize healthcare for everyone, everywhere. Our products guide patients to the best care and medications by inserting clinicians and pharmacists into a patient’s care journey through a modern, mobile app. Rightway is a front door to healthcare, giving patients the tools they need along with on-demand access to Rightway health guides, human experts that answer their questions and manage the frustrating parts of healthcare for them.

Since its founding in 2017, Rightway has raised over $300mm from investors including Khosla Ventures, Thrive Capital, Francisco Partners, and Tiger Global. We’re headquartered in New York City, with satellite offices in Denver and Dallas. Our clients rely on us to transform the healthcare experience, improve outcomes for their teams, and decrease their healthcare costs.

HOW WE LIVE OUR VALUES TO OUR TEAMMATES:

We’re seeking those with passion for healthcare and relentless devotion to our goal. We need team members that embody our core values:

1) We are human, firstOur humanity binds us together. We bring the same empathetic approach to every individual we engage with, whether it be our members, our clients, or each other. We are all worthy of respect and understanding and we engage in our interactions with care and intention. We honor our stories. We listen to—and hear—each other, we celebrate our differences and similarities, we are present for each other, and we strive for mutual understanding.

2) We redefine what is possibleWe always look beyond the obstacles in front of us to imagine new solutions. We approach our work with inspiration from other industries, other leaders, and other challenges. We use ingenuity and resourcefulness when faced with tough problems.

3) We debate then commitWe believe that a spirit of open discourse is part of a healthy culture. We understand and appreciate different perspectives and we challenge our assumptions. When working toward a decision or a new solution, we actively listen to one another, approach it with a “yes, and” mentality, and assume positive intent. Once a decision is made, we align and champion it as one team.

4) We cultivate gritChanging healthcare doesn’t happen overnight. We reflect and learn from challenges and approach the future with a determination to strive for better. In the face of daunting situations, we value persistence. We embrace failure as a stepping stone to future success. On this journey, we seek to act with guts, resilience, initiative, and tenacity.

5) We seek to delightHealthcare is complicated and personal. We work tirelessly to meet the goals of our clients while also delivering the best experience to our members. We recognize that no matter the role or team, we each play a crucial part in our members’ care and take that responsibility seriously. When faced with an obstacle, we are kind, respectful, and solution-oriented in our approach. We hold ourselves accountable to our clients and our members’ success.

Rightway is proud to be an Equal Opportunity Employer that believes in the strength of diverse thought, beliefs, backgrounds, and education. We foster an inclusive culture where differences are celebrated to drive the best business decisions possible. We do not discriminate on any basis protected by applicable law. All employment decisions are based on merit, qualifications, need, and performance.