Senior Manager, Medicare Utilization Management Pharmacist

About Judi Health

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers,

• Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and

• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform.

Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health.

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

Salary Range
$150,000—$160,000 USD

All employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance. 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.

Judi Health 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.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy.