Manager, Clinical Review and Quality Assurance

About This Opportunity

We are representing a confidential healthcare technology organization in their search for a Manager, Clinical Review and Quality Assurance. This is a strategic leadership role overseeing the integrity, efficiency, and clinical operations of prior authorization programs within a pharmacy benefit management environment.

Our client is transforming how pharmacy benefits are delivered through innovative technology and evidence-based clinical strategies. This position offers the opportunity to lead a multidisciplinary team while directly impacting medication access and quality outcomes for hundreds of thousands of members nationwide.

Responsibilities

• Lead and mentor a high-performing team across Quality Assurance, medication policy, and business analysis functions
• Direct the prior authorization quality assurance program, including interrater reliability audits and team performance reviews
• Oversee PA platform strategy, technical enhancements, data governance, and clinical rule configuration
• Provide pharmacotherapy expertise for Pharmacy and Therapeutics Committee activities and formulary management
• Develop and execute evidence-based medication policies ensuring clinical safety and regulatory compliance
• Drive process improvements and technology enhancements using data-driven performance metrics
• Lead User Acceptance Testing (UAT), process documentation, and stakeholder training for system releases
• Bridge business requirements and technical execution to ensure operational excellence across PA programs

What We're Looking For

• Education: Doctor of Pharmacy (PharmD) required
• Licensure: Active, unrestricted Registered Pharmacist (RPh) license
• Experience: 10+ years in clinical pharmacy within Health Plan or PBM environments
• Technical Proficiency: 5+ years supporting prior authorization platforms, including ePA standards (NCPDP) and rule configuration experience with platforms such as Banjo Health or MHK
• Domain Expertise: Strong background in QA best practices, clinical utilization review, P&T committee support, and regulatory compliance
• Analytical Skills: Proven ability to translate complex data and business requirements into actionable system changes
• Communication: Exceptional communication and influencing skills with demonstrated success in fast-paced, collaborative environments
• Leadership: Track record of mentoring teams and driving organizational goals through strategic oversight

How We Work With You

Candidates interested in this confidential opportunity should apply directly through Get A Job.ai. Our talent team will conduct an initial screening to understand your background and qualifications. We will then submit qualified candidates to our client for consideration. Please do not attempt to contact the employer directly, as all communication should flow through our recruiting process to ensure confidentiality and proper representation.

Pay

This is a remote position available to candidates located throughout the United States. Compensation details will be discussed with qualified candidates during the screening process based on geographic location and experience level.

Equal Opportunity

Get A Job.ai is committed to inclusive hiring practices and equal employment opportunity. We partner with clients who value diversity and welcome candidates from all backgrounds to apply.