Utilization Management Specialist, PBA Client Services

CybSafe; Pennsylvania; Hybrid; USD 100,000 - 125,000; Full time

Job summary

This innovative firm seeks a Utilization Management Specialist to enhance client interactions and manage workflows effectively. In this hybrid role, you'll be the key liaison between clients and internal teams, ensuring efficient Prior Authorization processes and delivering high-quality service. You'll develop a deep understanding of UM workflows and collaborate with cross-functional teams to drive improvements. If you're passionate about making a difference in healthcare and enjoy working in a dynamic environment, this position offers a fantastic opportunity for career growth and professional development.

Qualifications

• 3+ years of experience in Clinical Utilization Management operations required.
• Deep understanding of Prior Authorization workflows and regulations.

Responsibilities

• Manage inquiries and escalations related to Prior Authorization and Utilization Management.
• Act as Subject Matter Expert within the PBA Account team.

Skills

Clinical Utilization Management operations

Prior Authorization workflows

Microsoft Office suite

Communication skills

Project management

Relationship building

Adaptability

Job description

Location: Hybrid (Local to NYC area)

Position Overview:

The Utilization Management Specialist is a client-facing role responsible for managing Utilization Management workflow and Prior Authorization Tool functionality topics directly with clients and account teams. They will act as the liaison between our internal PA teams and be the subject matter expert for anything UM-related. This position offers candidates a career growth opportunity while developing knowledge around UM workflows and technology.

This position reports to the Director, PBA Clinical Client Services

Position Responsibilities:

1. Manage inquiries and escalations from internal and external stakeholders related to Prior Authorization (PA)/Utilization Management (UM).
2. Develop deep knowledge of Capital Rx PA workflow and policies, working closely with clinical PA and PA Tool Product team.
3. Create and maintain PA workflow resources to serve as reference for Clinical Account Management teams and clients.
4. Act as Subject Matter Expert within the PBA Account team, managing client deliverables and discussions efficiently and timely.
5. Collaborate cross-functionally with Prior Authorization team and PA Tool Development team to stay updated on PA workflow process updates and improvements.
6. Provide account teams and clients comprehensive insight of regulatory requirements that apply to prior authorization operations across all lines of business within the PBA vertical, including but not limited to Medicare, Commercial, and Exchange.
7. Support client-level training and inquiries for Capital Rx’s internal PA tool.
8. Support implementation of new plans by acting as liaison with PA team to determine delegated functions, workflow, and expectations.
9. Maintain open communication with PA team and Development team on client-specific enhancement requests.
10. Assist with additional clinical projects assigned as needed, pending business needs.
11. Partner with account team members and internal support teams to provide best-in-class client service.
12. Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Required Qualifications:

1. 3+ years of Clinical Utilization Management operations experience required.
2. Experience working in a health plan setting preferred.
3. Deep understanding of PA workflows, regulations, and terminology.
4. Experience with Medicare utilization management preferred.
5. Ability to prioritize, quickly assess, and manage multiple tasks and adapt to continually changing situations.
6. Track record of building trusting internal and external relationships.
7. Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables.
8. Ability to work independently with minimal supervision, staying productive in a remote, high-volume work environment.
9. Proficient in Microsoft Office suite.
10. Ability to balance multiple complex projects simultaneously.
11. Exceptional written and verbal communication skills.
12. Extremely flexible, highly organized, and able to shift priorities easily.
13. Attention to detail & commitment to delivering high-quality work product.

Base Salary: $100,000 - $125,000

Visa Sponsorship: Capital Rx does not provide sponsorship to any candidates. This includes, but is not limited to those that require H1-B, TN, OPT, etc. Candidates must have authorization to work in the US at the time of application and throughout employment.

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.

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp, Capital Rx is executing its mission through the deployment of JUDI, the company’s cloud-native enterprise health platform, and a Single-Ledger Model, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy 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 pharmacy benefits and rebuilding trust in healthcare.

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.