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Role Description

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.

• 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

Qualifications

• 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%)

Benefits

• 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

Company Description

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.