Capital Rx · 16 hours ago
Senior Manager, Medicare Utilization Management Pharmacist
United States
Full-time
Remote
Mid, Senior Level
$150K/yr - $160K/yr
4+ years expJudi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans. In this role, you will manage and optimize Medicare prior authorization and appeals processes while leading a team of pharmacists and technicians to ensure compliance with CMS guidelines.
Hospital & Health Care
Responsibilities
Serve as the Medicare coverage determinations and redeterminations subject matter expert
Create and uphold robust policies and procedures for coverage determinations and redeterminations in accordance with CMS guidelines
Write and maintain department specific job aids/work instructions
Utilizing available data to forecast, optimize prior authorization staffing, and streamline workflow
Recruiting, onboarding, training, and managing of Medicare PA and Appeals pharmacists and technicians
Manage contracts with government, state, and other regulatory vendors
Maintain coverage determination member and prescriber notification letters
Oversee the draft of Medicare denial verbiage templates
Assist with IRE and CMS reporting
Actively participate in goal setting and regularly evaluate the performance of the team
Generate and deliver comprehensive reports on prior authorization to both internal and external stakeholders
Collaborate with other clinical operations team members as it pertains to utilization management review
Investigate and resolve escalated issues from clients and clinical partners as needed
Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed
Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls
Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance
Qualification
Required
2+ years of Medicare PA leadership experience required
Active, unrestricted, pharmacist license required
Exhibit strong written communication and oral presentation skills
Proficient in Microsoft office Suite with an emphasis on PowerPoint and Excel
Self-starter with the ability to work in a fast-paced environment with shifting priorities
Preferred
Experience with managing large remote teams preferred
Medicare implementation experience preferred
4+ years of experience at a PBM or health plan preferred
Company
Capital Rx
Capital Rx is now Judi Health! Navigate to our new page here: https://www.linkedin.com/company/judi-health
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
A. J. Loiacono
CEO
Ryan Kelly
CTO
Recent News
2025-10-01
Fierce Healthcare
2025-09-28
Tech Startups - Startups and Technology news
2025-09-28
Company data provided by crunchbase