JOB SUMMARY:The Manager Medical Drug Utilization Management is a working pharmacist leader responsible for daily operations, clinical quality, staff performance, and operational compliance. The Manager oversees coverage reviews, production, medical drug policy implementation, clinical training, and improves workflows to support timely decisions, appropriate therapy, and member access.
KEY RESPONSIBILITIES:- Supervise staff hiring, onboarding, scheduling, coaching, performance evaluations, and development; establish and monitor productivity, quality, and service expectations.
- Manage queues, assignments, aging cases, and coverage; adjust resources based on volume and complexity and oversee intake, documentation, routing, turnaround times, and notifications through closure.
- Oversee medical injectable, specialty, and high-cost drug reviews for appropriate criteria application, benefit interpretation and medical necessity.
- Resolve clinical and operational escalations with Medical Directors and other teams, including complex cases and member or provider concerns.
- Provide clinical review coverage and consultation as needed within authorized scope and established procedures.
- Oversee clinical audits of approvals, decisions, documentation, and denial communications; conduct annual interrater reviews and competency assessments, implement corrective actions, and verify improvement.
- Oversee policy pharmacist's development and maintenance of evidence-based medical drug criteria, policies, and prior authorization guidelines; monitor FDA approvals and quarterly drug-code changes and coordinate policy approval and implementation.
- Oversee assigned clinical vendor activities, including policy updates, clinical findings, preferred oncology drug list evaluation, and issue resolution.
- Use clinical and utilization data to identify and support preferred-product, biosimilar, Medicare Part B step therapy, site-of-care, and applicable diabetic supply management strategies.
- Coordinate provider education, academic detailing, member materials, website/EOC updates, and internal communications for policy and formulary changes; address implementation issues.
- Monitor applicable regulatory, accreditation, and contractual requirements; maintain audit readiness and coordinate responses and remediation with Compliance.
- Analyze volume, productivity, timeliness, quality, approval/denial trends, and capacity; identify workflow improvements and report risks and recommendations to the Director.
- Partner with the Director, Chief Medical Officer, and Finance to evaluate prior authorization effectiveness, track clinical interventions and adoption, and validate operational and financial results.
- Perform other related job-related duties as required or assigned.
QUALIFICATIONS:- Strong knowledge of managed care pharmacy, medical drug utilization management, evidence-based clinical policy development, and formulary management principles.
- Demonstrated understanding of Medicare Advantage, Commercial, and Marketplace benefits and medical drug UM operations.
- Ability to interpret clinical literature, treatment guidelines, benefit provisions, and applicable regulatory requirements and translate them into operational processes.
- Demonstrated ability to lead and coach staff, manage performance, prioritize competing demands, and build effective training and workflows.
- Strong analytical, organizational, critical thinking, and decision-making skills; ability to identify issues independently and lead improvements through implementation.
- Excellent written, verbal, and presentation skills and ability to collaborate with clinical, operational, technical, and leadership teams.
- Proficiency with Microsoft Office applications, UM systems, and performance reporting tools.
- Ability to provide on-call coverage for weekends and holidays as needed on scheduled rotation.
- Successful completion of a Health Care Sanctions background check.
EDUCATION/EXPERIENCE: - Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited School of Pharmacy.
- Active, unrestricted pharmacist license in any United States jurisdiction.
- A minimum of five years of clinical pharmacy experience in managed care pharmacy, health plan pharmacy, pharmacy benefit management, specialty pharmacy, hospital pharmacy, or a related clinical practice setting.
- Prior experience in medical drug utilization management, reviewing medical injectable and specialty medication requests, and applying clinical coverage criteria preferred.
- Prior supervisory or management experience, including staff performance management, training, and operational improvement, preferred.
- Experience with medical drug policy development, clinical audits, and implementation of preferred-product or other drug utilization strategies preferred.
