Clinical Pharmacy UM Manager: Lead Policy & Quality

CommunityCare, Inc.; Tulsa (OK); Presencial; USD 110.000 - 160.000; Jornada completa

Descripción de la vacante

CommunityCare, Inc. seeks a Manager Medical Drug Utilization Management to lead daily operations, guide clinical quality, and drive performance across pharmacy policy and prior authorization workflows.

You will oversee coverage reviews, staff development, and operational compliance to support timely decisions and member access. You will supervise clinical reviews, audits, policy development, and collaboration with Medical Directors, Finance, and Compliance to optimize utilization management in a

Formación

• Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited School of Pharmacy.
• Active, unrestricted pharmacist license in any United States jurisdiction.
• A minimum of five years of clinical pharmacy experience in managed care pharmacy, health plan pharmacy, or related setting.
• Prior supervisory or management experience preferred.
• Experience with medical drug utilization management and antibiotic/ policies preferred.

Responsabilidades

• Supervise staff hiring, onboarding, scheduling, coaching, performance evaluations, and development; establish and monitor productivity, quality, and service expectations.
• Manage queues, assignments, aging cases, and coverage; adjust resources based on volume and complexity and oversee intake, documentation, routing, turnaround times, and notifications through closure.
• Oversee medical injectable, specialty, and high-cost drug reviews for appropriate criteria application, benefit interpretation and medical necessity.
• Resolve clinical and operational escalations with Medical Directors and other teams, including complex cases and member or provider concerns.
• Provide clinical review coverage and consultation as needed within authorized scope and established procedures.
• Oversee clinical audits of approvals, decisions, documentation, and denial communications; conduct annual interrater reviews and competency assessments, implement corrective actions, and verify improvement.
• Oversee policy pharmacist’s development and maintenance of evidence-based medical drug criteria, policies, and prior authorization guidelines; monitor FDA approvals and quarterly drug-code changes and coordinate policy approval and implementation.
• Oversee assigned clinical vendor activities, including policy updates, clinical findings, preferred oncology drug list evaluation, and issue resolution.
• Use clinical and utilization data to identify and support preferred-product, biosimilar, Medicare Part B step therapy, site-of-care, and applicable diabetic supply management strategies.
• Coordinate provider education, academic detailing, member materials, website/EOC updates, and internal communications for policy and formulary changes; address implementation issues.
• Monitor applicable regulatory, accreditation, and contractual requirements; maintain audit readiness and coordinate responses and remediation with Compliance.
• Analyze volume, productivity, timeliness, quality, approval/denial trends, and capacity; identify workflow improvements and report risks and recommendations to the Director.
• Partner with the Director, Chief Medical Officer, and Finance to evaluate prior authorization effectiveness, track clinical interventions and adoption, and validate operational and financial results.
• Perform other related job-related duties as required or assigned.

Conocimientos

Pharmacy leadership

Managed care knowledge

Staff coaching

Clinical decision making

Regulatory/compliance awareness

Data-driven improvements

Collaboration with leadership

Microsoft Office / reporting tools

Educación

PharmD or BS in Pharmacy

Active pharmacist license (US)

Herramientas

UM systems

Performance reporting tools

MS Office

Descripción del empleo

CommunityCare, Inc. seeks a Manager Medical Drug Utilization Management to lead daily operations, guide clinical quality, and drive performance across pharmacy policy and prior authorization workflows.

You will oversee coverage reviews, staff development, and operational compliance to support timely decisions and member access. You will supervise clinical reviews, audits, policy development, and collaboration with Medical Directors, Finance, and Compliance to optimize utilization management in a