Manager, Clinical Review and Quality Assurance
Leads clinical review and prior authorization quality programs while managing platform strategy, medication policy, and a cross-functional team. Requires a PharmD, unrestricted RPh license, and 10+ years of clinical pharmacy experience in health plan or PBM environments.
About the job
Responsibilities
- Mentor and unify a high-performing team spanning quality assurance, medication policy, and business analysis.
- Direct the prior authorization quality assurance program, including interrater reliability audits and team performance reviews.
- Lead prior authorization platform strategy, technical enhancements, data governance, and clinical rule configuration.
- Provide pharmacotherapy expertise for Pharmacy and Therapeutics Committee activities, formulary management, and evidence-based medication policy development.
- Drive process and technology improvements using key performance metrics and data-driven insights.
- Document processes, lead User Acceptance Testing (UAT), and manage stakeholder training for system releases.
Requirements
- Doctor of Pharmacy (PharmD) degree.
- Active, unrestricted Registered Pharmacist (RPh) license.
- 10+ years of clinical pharmacy experience in health plan or pharmacy benefit manager environments.
- 5+ years supporting prior authorization platforms, including ePA standards and rule configuration.
- Strong experience with quality assurance practices, clinical utilization review, Pharmacy and Therapeutics Committee support, and regulatory compliance.
- Ability to translate complex data and business requirements into actionable system changes.
- Exceptional communication and influencing skills.
Preferred Experience
- Experience with NCPDP, Banjo Health, or MHK.
Compensation and Benefits
- Annual base salary range of $136,000–$192,000 USD, varying by geographic zone.
- Eligibility for bonuses, commissions, or equity may apply.
- Medical, pharmacy, dental, vision, life, AD&D, short- and long-term disability insurance.
- Flexible spending benefits, 401(k), discretionary paid time off, company holidays, wellness and commuter benefits.
- Paid parental leave, employee assistance program, and professional development and training opportunities.
Skills
Pharmd, Registered Pharmacist License, Clinical Pharmacy, Prior Authorization, Quality Assurance, Ncpdp, Banjo Health, Mhk, Data Governance, User Acceptance Testing, Formulary Management, Regulatory Compliance
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