Director of Utilization Management Review - Remote

Overview

The Director, Utilization Management Review will lead and oversee the development, implementation, and management of our Prior Authorization (PA) operations, ensuring compliance with regulatory and accreditation standards while driving exceptional client and member outcomes.

In Short

• Lead and develop a high-performing Prior Authorization (PA) team.
• Manage supervisors and scale the team for future growth.
• Oversee PA operations by monitoring production and quality metrics.
• Develop and optimize PA processes for operational excellence.
• Act as a clinical expert on prior authorization reviews.
• Manage client escalations and provide timely solutions.
• Lead strategic initiatives to improve PA operations.
• Ensure compliance with URAC and NCQA standards.
• Collaborate with internal teams for process improvements.
• Willingness to travel (10%-20%).

Requirements

• Bachelor's degree in Pharmacy.
• Advanced degree (PharmD, MSN, MPH, MBA) preferred.
• 10+ years of experience in prior authorization operations.
• 5 years in a leadership position.
• 3+ years in pharmacy or pharmacy benefit management preferred.
• Deep understanding of PA processes and clinical workflows.
• Knowledge of regulatory and accreditation requirements.
• Excellent analytical and problem-solving skills.
• Ability to work collaboratively with cross-functional teams.

Benefits

• Impact industry change in pharmacy benefits management.
• Work in a thriving culture.
• Competitive compensation and benefits.