AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.

Join us in improving health care outcomes for all! We promise to do what’s right, always.

Position Summary:

The Director of Utilization Management (UM) is a senior clinical and operational leader responsible for strategy, design, execution, and continuous improvement of Prior Authorization and utilization management programs. This role owns UM outcomes across clinical quality, regulatory compliance, operational performance, financial impact, and client experience. The Director will build and lead a high-performing UM organization, define scalable and sound UM strategies aligned to client benefit designs, and serve as a trusted advisor to internal leadership and external clients. This role partners closely with Clinical Strategy, P&T, Client Success, Compliance, Technology, and Executive Leadership to ensure UM programs deliver clinically appropriate care, operational excellence, and measurable value.

What you will do:

Strategic Leadership and Enterprise Impact:

Define and evolve the organization’s utilization management strategy, ensuring alignment with client benefit designs, affordability goals, regulatory requirements, and AffirmedRx’s transparent PBM model
Serve as a clinical and operational thought partner to executive leadership, advising on UM tradeoffs related to access, member experience, cost management, and regulatory risk
Translate client-specific goals and contractual requirements into tailored UM programs, guardrails, and workflows
Develop a multi-year UM roadmap, including technology enablement, automation, and electronic PA integration

Operational Oversight and Process Excellence:

Own end-to-end PA and UM operations, including intake, clinical review, peer-to-peer processes, determinations, and communications
Establish and monitor operational KPIs (turnaround times, quality accuracy, production metrics, escalation rates) and drive corrective actions
Optimize UM workflows to ensure scalability, audit readiness, and seamless integration with client and provider systems
Lead process improvement initiatives leveraging data, root cause analysis, and automation

Clinical Governance and Decision Support:

Ensure UM decisions are evidence-based, clinically sound, and aligned with plan design and coverage criteria
Oversee peer-to-peer review processes and ensure consistent, high-quality clinical determinations
Review and assess clinical literature to support UM criteria, policy updates, and provide guidance
Ensure accuracy and consistency of denial rationales, clinical communications, and member/provider-facing materials

Financial Stewardship and Value Delivery:

Partner with finance and clinical strategy teams to assess the financial impact of UM programs, including cost avoidance, utilization trends, and operational efficiency
Ensure UM strategies balance affordability with access, minimizing inappropriate utilization while avoiding unnecessary member or provider friction
Support budgeting, forecasting, and resource planning for UM operations

Client Operations and External Partnership:

Serve as an escalation point for complex or high-impact client UM issues, delivering timely, thoughtful, and defensible resolutions
Support client-facing discussions related to UM strategy, program performance, and regulatory compliance
Partner with Client Success and Sales teams to support implementations, renewals, and ongoing client satisfaction

Compliance, Accreditation, and Risk Management:

Ensure ongoing compliance with URAC, NCQA, and applicable regulatory requirements
Maintain audit readiness and lead UM-related accreditation activities, assessments, and corrective action plans
Stay current on evolving UM regulations, industry standards, and best practices, proactively adjusting programs as needed

What you need:

Bachelor's degree in Pharmacy
Advanced degree (PharmD, MSN, MPH, MBA) preferred
10+ years of experience in prior authorization operations, clinical services or related roles, with at least 5 years in a leadership position
3+ years of experience in pharmacy or pharmacy benefit management (PBM) preferred
Deep understanding of PA processes, staffing models, and clinical workflows
Knowledge of regulatory and accreditation requirements, particularly URAC and NCQA standards
Excellent analytical, organizational, and problem-solving skills
Ability to work collaboratively with cross-functional teams
Willingness and ability to travel (10%-20%)

What you get:

To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
To work in a culture where people thrive because when OUR team thrives, OUR business thrives
Competitive compensation, including health, dental, vision and other benefits

Note:

AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.

AffirmedRx, PBC

Open Positions (1)

Management

Director, Utilization Management