Manager, Clinical Review and Quality Assurance
Core
Lead clinical review operations and quality assurance for a prior authorization (PA) ecosystem, ensuring safety, compliance, and operational excellence.
Role type
Manager, Clinical Review Operations and Quality Assurance
Builds
Prior authorization programs, medication policies, and clinical rule configurations
Domain
Pharmacy Benefit Management (PBM) and Health Plan
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Pharmacotherapy expertise, QA program management, P&T committee support, formulary management, regulatory compliance, data governance, clinical rule configuration, stakeholder training, process documentation
Preferred skills
Technical system management, User Acceptance Testing (UAT), data-driven process improvement
Technologies
Banjo Health, MHK, NCPDP standards
Responsibilities
Mentor and unify a multidisciplinary team across QA, medication policy, and business analysis; Direct the PA quality assurance program overseeing interrater reliability audits; Lead PA platform strategy and technical enhancements; Provide pharmacotherapy expertise for P&T Committee activities and evidence-based policy development; Drive technology enhancements and monitor key performance metrics; Facilitate process documentation and manage stakeholder training for system releases
Seniority
Manager, hands-on leadership
