Review prior authorization requests, appeals, and overrides using clinical guidelines and benefit criteria.
Ensure compliance with federal, state, and internal regulations across Commercial, Exchange, Medicare, and Medicaid plans.
Provide clear, empathetic support to members, prescribers, and pharmacies via phone, while staying current with clinical guidelines.
Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. It is the intelligence platform powering benefits plans for millions of Americans, focused on operational efficiency and service excellence.
Supervises representatives, manages performance, and provides feedback through side-by-side and recorded call reviews.
Handles escalated calls, partners with business units, and coordinates team schedules to maximize efficiency.
Monitors volumes for pending queues and ensures timely processing of prior authorization forms.
PharMerica is a long-term care pharmacy services provider that supplies medications, clinical support, and pharmacy management to healthcare organizations across the United States. It operates as part of BrightSpring Health Services, combining personalized care with the resources of a national network.
Serve as clinical subject matter expert and operational driver for prior authorization.
Build tools, drive process improvements, and mentor peer pharmacists on clinical protocols.
Handle complex escalations, appeals, and cross-functional collaboration to scale clinical operations.
SmithRx is a venture-backed Health-Tech company disrupting the PBM market with cutting-edge technology. Since 2016, we have onboarded hundreds of thousands of members and pride ourselves on a mission-driven, collaborative culture.
Review prior authorization requests and make evidence-based decisions using clinical guidelines.
Ensure compliance with federal, state, and internal regulations while accurately documenting clinical decisions.
Provide clear, empathetic support to members, prescribers, and pharmacies, staying current with prescribing guidelines and regulatory changes.
SmithRx is a rapidly growing, venture-backed Health-Tech company that disrupts the expensive Pharmacy Benefit Management (PBM) sector with a next-generation drug acquisition platform. Since 2016, they have onboarded hundreds of thousands of members and pride themselves on a mission-driven, collaborative culture guided by values of Integrity, Courage, and Together.
Coordinates utilization review and prior authorization requests, ensuring accurate entry into the UM platform.
Provides customer service to providers and members, confirming benefits and answering authorization questions.
Facilitates communication between reviewers, hospitals, and physicians to ensure timely decisions.
University of Utah Health Plans is a patient-focused organization that enhances health through patient care, research, and education. It is part of a nationally ranked academic medical center with five hospitals and eleven clinics, fostering a culture of collaboration and excellence.
Approves and oversees medication ordering, compounding, and dispensing for patients.
Supervises pharmacy technicians and ensures compliance with state and federal regulations.
Participates in clinical initiatives, monitors patient progress, and educates healthcare staff.
The University of Rochester is a leading research university and academic medical center committed to learning, discovery, and healing. The institution values equity, integrity, and respect, fostering an inclusive culture for all employees.
Serve as the designated Pharmacist in Charge and fulfill all related responsibilities.
Review and approve licensing submissions, renewals, and regulatory documentation.
Collaborate with the operations and compliance team to support ongoing compliance.
MD Exam is a healthcare organization specializing in sterile compounding operations. They are a growing company with an experienced team dedicated to compliance and patient safety.
Serve as the designated Pharmacist-in-Charge, reviewing licensing submissions and regulatory documentation.
Work with pharmacy operations and compliance team to support ongoing compliance and Board-related discussions.
Provide professional guidance and identify issues requiring follow-up or corrective action.
MD Exam is a growing healthcare organization with established sterile compounding operations. It offers an experienced team support and a collaborative culture focused on patient safety and compliance.
Oversee system-level utilization management activities across the organization.
Ensure compliance with medical necessity criteria such as InterQual and Milliman.
Manage professional staff and review processes to optimize patient care.
Piedmont Healthcare is a healthcare system providing comprehensive medical services. It is a large organization focused on utilization management and quality care.
Performs pre-admission, admission, and continued stay reviews using approved medical necessity criteria.
Coordinates patient care and communicates with physicians, patients, caregivers, and third-party payers.
Manages patient progression through the healthcare system and proactively works with payers to secure certification and minimize denials.
Ochsner Health is a leading not-for-profit healthcare provider in the Gulf South, with 46 hospitals and 370+ care centers. It employs more than 38,000 team members and has been recognized as a top workplace and the No. 1 hospital in Louisiana.
Lead, coach, and onboard Utilization Management nurses while managing daily workloads and escalations.
Ensure reviews and determinations are timely, accurate, and compliant with CMS and Clover policies.
Collaborate with Medical Directors and cross-functional teams to improve workflows and member outcomes.
Clover Health provides data-driven healthcare plans for seniors, using the Clover Assistant to support physician decisions. The company is a mission-driven team of diverse experts focused on improving members' quality of life.
Maintain clinical drug lists and prior authorization documents, resolve drug list and benefit setup questions, and prepare reports and client business review materials.
Investigate claim rejections related to drug list platform configuration and coordinate with pharmacists and operational teams to meet deadlines.
Identify opportunities to improve accuracy and efficiency through technology, automation, and AI-enabled tools.
Prescryptive is a healthcare technology company enabling the direct access marketplace for prescription drugs. As an Equal Opportunity Employer, the company values bold aspirations and a passion for improving consumer health and wellbeing.
Review and process prior authorization requests for various medications.
Communicate prior authorization criteria to providers and act as a help desk.
Process requests via phone, fax, and web submission while maintaining HIPAA compliance.
Lumicera Health Services is a specialty pharmacy focused on optimizing patient well-being through transparency and stewardship. It fosters a diverse and creative work environment as part of the Navitus organization.
Provide exceptional phone-based customer service and process prescriptions with speed and accuracy.
Perform claim adjudication, billing, and eligibility checks while maintaining detailed patient records.
Act as a liaison between pharmacists and medical professionals, placing outbound calls to support patient care.
AnewHealth is a leading pharmacy care management company specializing in complex, chronic patient care. With over 1,400 team members and an award-winning culture, we serve more than 100,000 people across all 50 states.
Conduct clinical reviews of inpatient admissions and continued stays using approved medical necessity criteria.
Collaborate with physicians, care managers, and payer teams to resolve utilization concerns and prevent denials.
Support quality improvement initiatives, maintain accurate documentation, and communicate review outcomes effectively.
This role is with a partner company focused on healthcare utilization management, helping hospitals improve patient outcomes and ensure appropriate resource use. The team operates as a distributed remote group supporting care coordination, revenue integrity, and clinical compliance.
Develop and manage complex clinical product initiatives, including clinical criteria and product roadmaps.
Analyze market information, clinical guidelines, and member claims data to support clinical product management strategies.
Collaborate with leadership and cross-functional partners to execute product strategy and represent the Clinical department in customer sessions.
Prime Therapeutics is a pharmacy benefit manager (PBM) focused on reimagining pharmacy solutions to simplify health care. It is a large, purpose-driven organization that values diversity, inclusion, and equal opportunity.
Review and respond to phone and fax inquiries from members, providers, and pharmacies for prior authorization.
Use multiple applications and follow procedures to accurately document and resolve inquiries.
Provide excellent customer service and meet or exceed call center metrics.
The Cigna Group is dedicated to improving the health and vitality of those we serve through Cigna Healthcare and Evernorth Health Services. We are a major healthcare organization focused on enhancing the lives of our clients, customers, and patients.
Oversee medical necessity reviews for home health, acute, post-acute, and outpatient services for Medicare Advantage populations.
Collaborate with treating physicians, nursing teams, and external agencies to promote evidence-based care and appropriate resource utilization.
Apply CMS regulations, coverage determinations, MCG criteria, and medical policies in a fully remote, part-time physician leadership role.
Jobgether is an AI-powered job matching platform that connects candidates with employers. It uses objective screening to share top-fitting applicants with hiring companies, emphasizing data privacy and human oversight throughout the recruitment process.
Manage formularies, coverage determinations, and benefit design for PBM services.
Resolve clinical inquiries from members, clients, providers, and pharmacies.
Support P&T Committees with drug monographs, summaries, and medication policies.
OHSU is Oregon's only public academic health center with hospitals, clinics, and research schools. It is Portland's largest employer and a national research hub, welcoming diverse backgrounds.
Manage prescription workflows and provide clinical and operational support to the pharmacy enablement team.
Collaborate with RNs, providers, and coaches to coordinate care and resolve member issues.
Process clinical tickets, route faxes and records, and follow SOPs to maintain compliance.
Virta Health works to reverse metabolic disease in one billion people using technology, personalized nutrition, and virtual care delivery. It is a remote-first company backed by over $350 million from top-tier investors, partnering with health plans, employers, and government organizations.