Manager, Clinical Review and Quality Assurance

This is a fully remote position, open to applicants in Alabama, +45 more states.

📋 Description

• Guide and harmonize a high-performing team across Quality Assurance, medication policy, and business analysis to achieve organizational objectives.

• Oversee the quality assurance program for prior authorization, managing interrater reliability audits and evaluating team performance.

• Direct the strategy for prior authorization platforms, including technical enhancements, data governance, and clinical rule configuration.

• Offer pharmacotherapy expertise for Pharmacy and Therapeutics (P&T) Committee activities, formulary management, and the creation of evidence-based medication policies.

• Propel technology improvements and track key performance metrics utilizing data-driven insights.

• Lead the documentation of processes, manage User Acceptance Testing (UAT), and conduct stakeholder training for system implementations.

• Ensure that prior authorization programs are safe, evidence-based, compliant, and operationally outstanding.

⛳️ Requirements

• A Doctor of Pharmacy (PharmD) degree is required.

• Must possess an active, unrestricted Registered Pharmacist (RPh) license.

• At least 10 years of experience in clinical pharmacy, particularly within Health Plan or Pharmacy Benefit Manager (PBM) settings.

• A minimum of 5 years of experience supporting prior authorization platforms.

• Familiarity with electronic Prior Authorization (ePA) standards (NCPDP) and rule configuration, including platforms like Banjo Health and MHK.

• Strong expertise in Quality Assurance best practices, clinical utilization review, support for P&T committees, and adherence to regulatory compliance.

• Demonstrated ability to convert complex data and business requirements into actionable system modifications.

• Outstanding communication and influencing skills with a proactive approach in dynamic environments.

🏝️ Benefits

• Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life Insurance along with AD&D Insurance.

• Flexible Spending Benefits.

• 401(k) Retirement Savings Program.

• Short-term and long-term disability coverage.

• Discretionary Paid Time Off.

• Paid Company Holidays.

• Wellness Benefits.

• Commuter Benefits.

• Paid Parental Leave benefits.

• Employee Assistance Program (EAP).

• Well-stocked kitchen in office locations.

• Opportunities for professional development and training.

• Time off programs.

• Support for mental health.