Director, Utilization Management Review

AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.

Join us in improving health care outcomes for all!  We promise to do what’s right, always.

Position Summary:
The Director, Utilization Management Review will lead and oversee the development, implementation, and management of our Prior Authorization (PA) operations. This role will be responsible for building and managing a high-performing PA team, establishing efficient processes and procedures, and ensuring compliance with regulatory and accreditation standards. The Director will work closely with internal teams and external stakeholders to support seamless PA operations, maintain accreditation requirements, and drive exceptional client and member outcomes.

What you will do:

Leadership and Team Management:

•    Lead and develop a high-performing Prior Authorization (PA) team, including hiring, onboarding, training, and managing performance 
•    Manage supervisors and scale the team to support future growth, ensuring efficient resource allocation through effective staffing models
•    Oversee PA operations by monitoring production and quality metrics to drive performance and operational excellence 

Operational Oversight and Process Improvement: 

•    Develop and optimize PA processes and procedures to ensure operational excellence, scalability, and seamless integration with client systems
•    Oversee clinical review activities, including peer-to-peer reviews and timely communication of approval and denial determinations to prescribers, members, and stakeholders 
•    Collaborate with internal teams, such as formulary management, to implement changes, maintain accurate denial language, and support process improvements

Clinical Support and Guidance:

•    Act as a clinical expert on prior authorization reviews and evaluations according to criteria and plan design 
•    Ensure accuracy of clinical guidance support provided to members, prescribers, and internal teams related to prior authorizations and clinical alternatives
•    Review and evaluate clinical literature to support decision-making and recommendations to providers 

Client Operations and Strategic Initiatives:

•    Manage client escalations, providing timely solutions to maintain satisfaction and trust while driving continuous process improvements
•    Lead strategic initiatives, including technology migrations, electronic PA integration, and workflow enhancements, to improve PA operations and client outcomes 
•    Ensure compliance with URAC and NCQA standards, staying current with industry regulations and supporting audits as needed  

What you need:

•    Bachelor's degree in Pharmacy
•    Advanced degree (PharmD, MSN, MPH, MBA) preferred
•    10+ years of experience in prior authorization operations, clinical services or related roles, with at least 5 years in a leadership position
•    3+ years of experience in pharmacy or pharmacy benefit management (PBM) preferred
•    Deep understanding of PA processes, staffing models, and clinical workflows
•    Knowledge of regulatory and accreditation requirements, particularly URAC and NCQA standards
•    Excellent analytical, organizational, and problem-solving skills
•    Ability to work collaboratively with cross-functional teams
•    Willingness and ability to travel (10%-20%)

What you get:
•    To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
•    To work in a culture where people thrive because when OUR team thrives, OUR business thrives
•    Competitive compensation, including health, dental, vision and other benefits

Note:  
AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.