Manager, Clinical Quality Assurance - PBM

DescriptionRapidly Growing Player in the Pharmacy Benefits Management (PBM) marketplaceseeks a Manager, Clinical Quality Assurance who willact as subject matter expert on prior authorization and appeals operations that are compliant for multiple lines of business. Some of the expected job functions **Develop and maintain prior authorization policies and procedures for all lines of business compliant with federal, state, and other regulationsEnsure prior authorization processes are adherent to URAC, NCQA, and other accrediting bodiesWork with Commercial and Government PA managers to revise job aids, work instructions, verbiage templates and reference documents as neededSupport PA team on CDAG, ODAG, and data validation auditsManage Quality Assurance pharmacists and technicians Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as neededThe compensation plan includes a competitive salary ($145,000 - $155,000 d/o/e), plus bonus and benefits.This position can be filled "remotely", or as "hybrid", should the candidate live in the NYC-Metro area.RequirementsThe ideal candidate for this position has at least two (2) years of prior authorization review and/or appeals experience in the Medicare space.Active, unrestricted, pharmacist license required (in good standing)2+ years of compliance or regulatory experience at a PBM or health plan requiredExtensive knowledge of how to operationalize Medicare, ERISA, and state-regulated prior authorization requirements requiredStrong oral and written communication skills requiredIntermediate to advanced Microsoft Excel skills requiredQualified candidates should send their resumes in MS Word format ** mail@

Created: 2025-03-01