Senior Manager - Medicare Utilization Management Pharmacist

1w1 week ago

Capital Rx

Remote · Full-time · $150,000 – $160,000

About this role

Judi Health provides comprehensive solutions including Capital Rx for pharmacy benefit management, Judi Health for health benefit management, and Judi Enterprise Health Platform for claim workflows. In this role, you manage and optimize Medicare prior authorization and appeals processes, ensure CMS compliance, and oversee a team of pharmacists and technicians. Location is Remote for non-local or Hybrid for NYC or Denver area.

You lead creation and maintenance of policies, procedures, and job aids to enhance efficiency, forecast staffing needs, and streamline workflows. Responsibilities include managing regulatory vendor contracts, member and provider communications, and Medicare denial verbiage templates. You assist with IRE and CMS reporting while performing clinical pharmacy functions like prior authorization reviews.

As a people leader, you recruit, onboard, train, and manage Medicare PA and appeals pharmacists and technicians. You actively participate in goal setting, evaluate team performance, and drive adherence to compliance standards including the Capital Rx Code of Conduct. Collaborate with internal stakeholders on utilization management and resolve escalated issues.

Generate comprehensive reports for internal and external stakeholders and work with the Director on projects and initiatives. Together with clients, rebuild trust in U.S. healthcare using scalable, secure platforms. Visit www.judi.health to learn more.

Requirements

2+ years of Medicare PA leadership experience
Experience managing large remote teams
Deep knowledge of CMS guidelines for coverage determinations
Expertise in Medicare prior authorization and appeals processes
Familiarity with IRE and CMS reporting requirements
Experience overseeing clinical pharmacy functions including override requests
Ability to investigate and resolve escalated client and partner issues

Responsibilities

Serve as subject matter expert on Medicare coverage determinations and redeterminations
Create and uphold policies and procedures for coverage determinations and redeterminations per CMS guidelines
Write and maintain department-specific job aids and work instructions
Utilize data to forecast, optimize prior authorization staffing, and streamline workflows
Recruit, onboard, train, and manage Medicare PA and appeals pharmacists and technicians
Manage contracts with government, state, and regulatory vendors
Maintain coverage determination member and prescriber notification letters
Generate and deliver reports on prior authorization to internal and external stakeholders