Associate Vice President, Utilization Management Review

Join to apply for the Associate Vice President, Utilization Management Review role at AffirmedRx, a Public Benefit CorporationAffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology. Join us in improving health care outcomes for all! We promise to do what/'s right, always.Position SummaryThe AVP of Utilization Management will lead and oversee the development, implementation, and management of our Prior Authorization (PA) operations. This role will be responsible for building and managing a high-performing PA team, establishing efficient processes and procedures, and ensuring compliance with regulatory and accreditation standards. The AVP will work closely with internal teams and external stakeholders to support seamless PA operations, maintain accreditation requirements, and drive exceptional client and member outcomes.What you will doLeadership and Team ManagementLead and develop a high-performing Prior Authorization (PA) team, including hiring, onboarding, training, and managing performanceLead and scale the team to support future growth, ensuring efficient resource allocation through effective staffing modelsOversee PA operations by monitoring production and quality metrics to drive performance and operational excellenceOperational Oversight and Process ImprovementDevelop and optimize PA processes and procedures to ensure operational excellence, scalability, and seamless integration with client systemsOversee clinical review activities, including peer-to-peer reviews and timely communication of approval and denial determinations to prescribers, members, and stakeholdersCollaborate with internal teams, such as formulary management, to implement changes, maintain accurate denial language, and support process improvementsClinical Support and GuidanceAct as a clinical expert on prior authorization reviews and evaluations according to criteria and plan designEnsure accuracy of clinical guidance support provided to members, prescribers, and internal teams related to prior authorizations and clinical alternativesReview and evaluate clinical literature to support decision-making and recommendations to providersClient Operations and Strategic InitiativesManage client escalations, providing timely solutions to maintain satisfaction and trust while driving continuous process improvementsLead strategic initiatives, including technology migrations, electronic PA integration, and workflow enhancements, to improve PA operations and client outcomesEnsure compliance with URAC and NCQA standards, staying current with industry regulations and supporting audits as neededWhat you needBachelor/'s degree in PharmacyAdvanced degree (PharmD, MSN, MPH, MBA) preferred15 years of experience in prior authorization operations, clinical services or related roles, with at least 5 years in a leadership position3+ years of experience in pharmacy or pharmacy benefit management (PBM) preferredDeep understanding of PA processes, staffing models, and clinical workflowsKnowledge of regulatory and accreditation requirements, particularly URAC and NCQA standardsExcellent analytical, organizational, and problem-solving skillsAbility to work collaboratively with cross-functional teamsWillingness and ability to travel (10%-20%)What you getTo impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomesTo work in a culture where people thrive because when OUR team thrives, OUR business thrivesCompetitive compensation, including health, dental, vision and other benefitsNoteAffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.Seniority levelExecutiveEmployment typeFull-timeJob functionHealth Care ProviderIndustriesHospitals and Health Care #J-18808-Ljbffr

Created: 2025-09-18