Manager, Medicare Utilization Management Pharmacist

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

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  Serve as the Medicare coverage determinations and redeterminations subject matter expert

  
  

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

  
  

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  Write and maintain department specific job aids/work instructions

  
  

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

  
  

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

  
  

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  Manage contracts with government, state, and other regulatory vendors

  
  

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  Maintain coverage determination member and prescriber notification letters

  
  

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  Oversee the draft of Medicare denial verbiage templates

  
  

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  Assist with IRE and CMS reporting

  
  

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

  
  

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

  
  

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

  
  

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

  
  

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

  
  

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

  
  

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

  
  

Required Qualifications:

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  2+ years of Medicare PA leadership experience required

  
  

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  Experience with managing large remote teams preferred

  
  

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  Medicare implementation experience preferred

  
  

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

  
  

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  Active, unrestricted, pharmacist license required

  
  

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  Exhibit strong written communication and oral presentation skills

  
  

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

  
  

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

  
  

Base Salary: $150,000 - $165,000

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.

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.

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.