Oversee clinical pharmacy operations, including prior authorization and appeal reviews, override requests, member and provider support, and queue management while ensuring decisions meet medical necessity, contractual, and regulatory requirements. Guide and train pharmacists, serve as a clinical subject matter expert, and lead quality and workflow improvements to support better care outcomes and efficient operations.
The Clinical Programs Specialist manages day-to-day clinical program operations, vendor partnerships, and program workflows. They ensure consistent execution of processes, monitor deliverables, and facilitate communication between internal and external stakeholders.
The Manager of the Special Investigations Unit leads the pharmacy fraud, waste, and abuse investigations program, overseeing intake, strategy, and resolution. They also partner with cross-functional teams to ensure regulatory compliance and provide actionable insights to leadership.
The VP of Insured Products will oversee business development and manage the company's strategy for insured product offerings, including stop loss and captive management. They will also lead, mentor, and train sales executives while collaborating on product development and operational efficiency.
The Utilization Management Pharmacist reviews prior authorization requests and appeals to ensure safe and effective medication use. They also provide clinical support to members and providers while maintaining compliance with regulatory standards.
The Supervisor oversees a team of pharmacists and technicians managing prior authorization and appeals processes across multiple lines of business. They are responsible for ensuring compliance, optimizing workflows, and performing clinical pharmacy functions including complex case reviews.
The Appeals Pharmacist is responsible for reviewing clinical coverage determinations and appeals for Commercial and Medicare lines of business. They will collaborate with Medical Directors and providers to facilitate appeal requests while ensuring quality and productivity standards are met.
Design, develop, and productionize machine learning solutions including document understanding, search, and generative AI applications. Collaborate with cross-functional teams to integrate AI models into backend services while ensuring data security and HIPAA compliance.
Design, develop, and productionize machine learning solutions including GenAI, NLP, and search applications. Collaborate with cross-functional teams to integrate AI models into backend services while ensuring system robustness and HIPAA compliance.
Prepare and validate prior authorization requests by obtaining necessary clinical information from providers and prescribers. Triage communications from members and pharmacies while ensuring adherence to HIPAA guidelines and internal procedures.
Develop and productionize multimodal LLMs and AI-based automation tools for healthcare applications such as document understanding and virtual agents. Manage the full ML lifecycle from data pipeline creation and model training to validation and deployment.
Review and make evidence-based decisions on prior authorizations, appeals, and override requests while ensuring regulatory compliance. Provide clinical support and guidance to members, prescribers, and pharmacies via phone.
Responsible for processing first, second level, and external appeals for various lines of business including Commercial, Exchange, and Medicare. The role involves verifying case qualifications, coordinating with pharmacists and medical directors, and communicating with members and providers.
The Senior AI/ML Applied Scientist will investigate and evaluate the latest LLM and MLM models for healthcare applications, develop data pipelines, and productionize machine learning solutions. They will also participate in the complete lifecycle of ML model development and ensure compliance with healthcare data regulations.
