Capital Rx
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Manager, Utilization Management Oversight
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Manager, Utilization Management Oversight
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Capital Rx Get AI-powered advice on this job and more exclusive features. Position Summary
Please ensure you read the below overview and requirements for this employment opportunity completely.
Acts as subject matter expert on prior authorization and appeals operations that are compliant to federal, state, and other regulatory standards for multiple lines of business including Commercial, Commercial Exchange, FEHB, Medicare Part B&D, and Medicaid, and responsible for internal and external oversight. Position Summary
Acts as subject matter expert on prior authorization and appeals operations that are compliant to federal, state, and other regulatory standards for multiple lines of business including Commercial, Commercial Exchange, FEHB, Medicare Part B&D, and Medicaid, and responsible for internal and external oversight.
Position Responsibilities
Develop and maintain prior authorization policies and procedures for all lines of business compliant with federal, state, and other regulations Ensure prior authorization processes are adherent to URAC, NCQA, and other accrediting bodies Provide oversight on utilization management turnaround times to ensure compliance with regulations and accreditations Work with Commercial and Government PA managers to revise job aids, work instructions, verbiage templates and reference documents as needed Develop and maintain compliant prior authorization notifications for all lines of business including but not limited to approval and denial letter templates Represent PA team on audits from regulatory bodies including URAC, NCQA Support PA team on CDAG, ODAG, and data validation audits Stakeholder for prior authorization system to ensure compliance with all regulations Works with Senior Director, Prior Authorization on other responsibilities, projects, and initiatives as needed Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.
Minimum Qualifications
Active, unrestricted, pharmacist license required 1+ years prior authorization review or appeals experience required 2+ years of compliance or regulatory experience at a PBM or health plan required Extensive knowledge of how to operationalize Medicare, ERISA, and state-regulated prior authorization requirements required Strong oral and written communication skills required Intermediate to advanced Microsoft Excel skills required
Preferred Qualifications
Experience with Texas Department of Insurance (TDI) or other state-regulated markets NCQA and/or URAC accreditation experience preferred MS/MLS Health Law/Policy or JD with Pharm.D. preferred
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.
Salary Range
$145,000—$155,000 USD
About Capital Rx
Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.
Capital Rx 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.Seniority level
Seniority levelMid-Senior level Employment type
Employment typeFull-time Job function
Job functionHealth Care Provider IndustriesHospitals and Health Care Referrals increase your chances of interviewing at Capital Rx by 2x Get notified about new Clinic Manager jobs in
Denver, CO . Behavioral Health / Substance Use Nurse Care Manager, Adult We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
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Manager, Utilization Management Oversight
role at
Capital Rx Continue with Google Continue with Google 6 days ago Be among the first 25 applicants Join to apply for the
Manager, Utilization Management Oversight
role at
Capital Rx Get AI-powered advice on this job and more exclusive features. Position Summary
Please ensure you read the below overview and requirements for this employment opportunity completely.
Acts as subject matter expert on prior authorization and appeals operations that are compliant to federal, state, and other regulatory standards for multiple lines of business including Commercial, Commercial Exchange, FEHB, Medicare Part B&D, and Medicaid, and responsible for internal and external oversight. Position Summary
Acts as subject matter expert on prior authorization and appeals operations that are compliant to federal, state, and other regulatory standards for multiple lines of business including Commercial, Commercial Exchange, FEHB, Medicare Part B&D, and Medicaid, and responsible for internal and external oversight.
Position Responsibilities
Develop and maintain prior authorization policies and procedures for all lines of business compliant with federal, state, and other regulations Ensure prior authorization processes are adherent to URAC, NCQA, and other accrediting bodies Provide oversight on utilization management turnaround times to ensure compliance with regulations and accreditations Work with Commercial and Government PA managers to revise job aids, work instructions, verbiage templates and reference documents as needed Develop and maintain compliant prior authorization notifications for all lines of business including but not limited to approval and denial letter templates Represent PA team on audits from regulatory bodies including URAC, NCQA Support PA team on CDAG, ODAG, and data validation audits Stakeholder for prior authorization system to ensure compliance with all regulations Works with Senior Director, Prior Authorization on other responsibilities, projects, and initiatives as needed Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.
Minimum Qualifications
Active, unrestricted, pharmacist license required 1+ years prior authorization review or appeals experience required 2+ years of compliance or regulatory experience at a PBM or health plan required Extensive knowledge of how to operationalize Medicare, ERISA, and state-regulated prior authorization requirements required Strong oral and written communication skills required Intermediate to advanced Microsoft Excel skills required
Preferred Qualifications
Experience with Texas Department of Insurance (TDI) or other state-regulated markets NCQA and/or URAC accreditation experience preferred MS/MLS Health Law/Policy or JD with Pharm.D. preferred
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.
Salary Range
$145,000—$155,000 USD
About Capital Rx
Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.
Capital Rx 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.Seniority level
Seniority levelMid-Senior level Employment type
Employment typeFull-time Job function
Job functionHealth Care Provider IndustriesHospitals and Health Care Referrals increase your chances of interviewing at Capital Rx by 2x Get notified about new Clinic Manager jobs in
Denver, CO . Behavioral Health / Substance Use Nurse Care Manager, Adult We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr