• 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 • 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 • 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 • 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 • 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 • 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