Team Description: The Clinical Pharmacist, Utilization Management is a member of the RightwayRx Operations team reporting to the Senior Director Clinical Strategy. This role will assist PBM Operations leadership in developing our UM strategy, implementing the strategy on our workflow platform, and actively work UM cases.
Role Description: Our pharmacy benefit management (PBM) offering represents an important growth area for Rightway.Helping clients better manage pharmacy spend to make drugs more affordable for their employees and dependents is critical to their business sustainability.RightwayRx is responsible for designing, building and operating a new-to-the-world PBM model base on our core tenets: fairness & transparency, unlocking the supply chain, supporting the physician-patient relationship, and utilizing navigation to empower consumers
Continual review of UM operational processes to ensure effective and compliant delivery of PBM services to our clients.
Support all lines of business via reviewing utilization management requests for coverage that are clinically appropriate and cost effective
Coordinate with Pharmacy technicians, Pharmacists, and/or Medical Directors on UM activities
Ensure cases are reviewed in accordance with State and/or Federal guidelines including turnaround time requirements
As needed, discuss clinical strategy and decision rationale with prescribers
Participate in the quality review and inter-rater reliability processes
Supports P&T process including the development of therapeutic class/drug monographs as needed
Research and develop therapy-specific clinical policies and utilization management programs such as Prior Authorization, Step Therapy, Quantity Limit, and/or Coverage Determination programs
Support Clinical Operations leadership and coordinate with Pharmacy Navigation team as needed
Work experience: 1 year experience coordinating medication selection with prescribers and their care teams. Preferred: 1-3+ years of managed care (PBM or health plan) prior authorization experience
Pharmacist license in good standing in state of residence.Willingness to achieve and maintain licensure in multiple states (if needed)
Location information:Denver, CO
Important characteristics of ideal candidate:Detail-oriented, intellectually and clinically curious, good listener, empathetic, ability to challenge status quo, values exemplar
Specific skills needed for job:Pharmacy benefit knowledge, strong clinical skills, effective & creative problem-solver, ability to prioritize and manage through change. Solid communication skills, ability to lead projects and influence others even without direct reporting line ownership
Internal Number: 78
About Rightway Healthcare
At Rightway we are committed to creating a diverse environment and are proud to be an equal opportunity employer. We hire for the best talent and actively seek diversity of thought processes, beliefs, background and education. Rightway fosters an inclusive culture where differences are celebrated to drive the best business decisions possible.
We are committed to equal opportunity and fairness regardless of race, color, religion, sex, gender identity, sexual orientation, nation of origin, ancestry, age, physical or mental disability, country of citizenship, medical condition, marital or domestic partner status, family status, family care status, military or veteran status or any other basis protected by local, state or federal laws.
Rightway Healthcare was founded in early 2017 by a team of dedicated healthcare, business and technology leaders. Rightway is a technology platform that provides employees and their families with the support, information and advocacy they need to be better healthcare consumers.
We combine a high-tech consumer portal with a high-touch dedicated concierge environment to provide consumers with the same level of support and guidance they would receive if ...they had a doctor in the family. We are focused on personalization, implementation, advocacy and results.
Rightway works with employers from 100 – 25,000 employees to provide an ecosystem of healthcare navigation for employees. We are committed to generating high member satisfaction scores, industry leading engagement and a quantifiable ROI for every employer. Our approach is rooted in analytics and guided by a bottom-up understanding of a population.
Rightway is privately financed, having raised over $130mm to date from investors such as Thrive Capital.
It is headquartered out of New York City. We also have remote offices in Miami, Denver, and San Francisco.