Manager, Medicare Utilization Management Pharmacist

Capital Rx; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

A leading health technology company seeks a Medicare Prior Authorization Manager to oversee a dynamic team, ensuring compliance with CMS guidelines. This role involves managing contracts, optimizing workflows, and driving team performance in a fast-paced environment.

Qualifications

• 2+ years of Medicare PA leadership experience required.
• Experience with managing large remote teams preferred.

Responsibilities

• Manage and optimize Medicare prior authorization processes.
• Recruit, onboard, and train pharmacists and technicians.
• Generate and deliver comprehensive reports on prior authorization.

Skills

Leadership

Communication

Microsoft Office Suite

Job description

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Location: Remote (For Non-Local) or Hybrid (Local to NYC or Denver area)

In this role, you will play a key part in managing and optimizing Medicare prior authorization and appeals processes, ensuring compliance with CMS guidelines while overseeing a dynamic team of pharmacists and technicians. You'll lead the creation and maintenance of policies, procedures, and job aids to enhance operational efficiency, forecast staffing needs, and streamline workflows.

Your responsibilities will also include managing contracts with regulatory vendors, overseeing member and provider communications, and actively collaborating with internal stakeholders to support clinical operations and utilization management. As a people leader, you will drive team performance, provide training, and ensure adherence to compliance standards.

Position Responsibilities:

Serve as the Medicare coverage determinations and redeterminations subject matter expert

Create and uphold robust policies and procedures for coverage determinations and redeterminations in accordance with CMS guidelines

Write and maintain department specific job aids/work instructions

Utilizing available data to forecast, optimize prior authorization staffing, and streamline workflow

Recruiting, onboarding, training, and managing of Medicare PA and Appeals pharmacists and technicians

Manage contracts with government, state, and other regulatory vendors

Maintain coverage determination member and prescriber notification letters

Oversee the draft of Medicare denial verbiage templates

Assist with IRE and CMS reporting

Actively participate in goal setting and regularly evaluate the performance of the team

Generate and deliver comprehensive reports on prior authorization to both internal and external stakeholders

Collaborate with other clinical operations team members as it pertains to utilization management review

Investigate and resolve escalated issues from clients and clinical partners as needed

Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed

Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls

Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Required Qualifications:

2+ years of Medicare PA leadership experience required

Experience with managing large remote teams preferred

4+ years of experience at a PBM or health plan preferred

Exhibit strong written communication and oral presentation skills

Proficient in Microsoft office Suite with an emphasis on PowerPoint and Excel

Self-starter with the ability to work in a fast-paced environment with shifting priorities

About Capital Rx

Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.

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.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.