Manager, Clinical Review – Quality Assurance

This is a fully remote position, open to applicants in Alabama, +46 more states.

📋 Description

• Guide and consolidate a high-achieving team encompassing QA, medication policy, and business analysis.

• Manage the quality assurance program for prior authorization.

• Supervise interrater reliability audits and assess team performance.

• Spearhead the strategy for prior authorization platforms, including technical improvements, data governance, and clinical rule setup.

• Offer pharmacotherapy knowledge for P&T Committee initiatives, formulary management, and the formulation of evidence-based medication policies.

• Propel technological advancements and track key performance indicators through data-driven insights.

• Ensure process documentation is effectively facilitated.

• Oversee User Acceptance Testing (UAT).

• Coordinate stakeholder training for system updates.

⛳️ Requirements

• Doctor of Pharmacy (PharmD) is mandatory.

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

• Minimum of 10 years of experience in clinical pharmacy, particularly in Health Plan or PBM settings.

• At least 5 years of experience supporting PA platforms.

• Familiarity with ePA standards (NCPDP).

• Proficient in rule configuration, such as Banjo Health or MHK.

• Strong understanding of QA best practices.

• Experience in clinical utilization review.

• Background in supporting P&T committees.

• Knowledge of regulatory compliance.

• Capability to convert complex data and business needs into implementable system modifications.

• Outstanding communication and influencing abilities.

• Proactive approach in dynamic environments.

🏝️ Benefits

• Medical, Pharmacy, Dental, Vision, Life Insurance, and 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 available at office locations.

• Opportunities for professional development and training.

• Potential for bonuses, commissions, or equity.

• Mental health support services.