Manager, Clinical Operations

Job Description

Job Description

Job Title : Manager, Clinical Operations

Job Location : Louisville, KY, USA

Job Location Type : Remote

Job Contract Type : Full-time

Job Seniority Level : Mid-Senior level

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 whats right, always.

Position Summary :

The Manager, Clinical Operations will oversee the management and optimization of clinical coding processes, benefit setups, and regulatory compliance while ensuring a high level of team performance. This role will drive efficient implementations, maintain compliance standards such as URAC accreditation, and support formulary and benefit updates to enhance client and member satisfaction.

What you will do :

• Team Leadership :
• Onboard, train, and manage staff, including clinical coding team members, fostering professional growth and operational excellence
• Provide mentorship and performance evaluations to maintain a high-performing team
• Create, maintain, and update department policies and procedures
• Clinical Operations Oversight :
• Oversee coding updates in claims adjudication platform and ensure accurate implementation of clinical benefit setups and formulary updates
• Manage and monitor the maintenance of ACA / preventive drug lists to ensure compliance with regulatory requirements
• Assess Medispan drug database changes and impact on formulary and benefit setup
• Testing and Quality Assurance :
• Supervise pre-testing and post-testing of formulary and benefit changes to ensure accuracy and functionality before deployment
• Troubleshoot and resolve escalations related to clinical coding, benefit setups, and other operational issues
• Implementation Leadership :
• Serve as the Clinical Implementations Coding Lead for new client onboarding and benefit implementation projects
• Coordinate with cross-functional teams to deliver seamless and timely implementations
• Regulatory and Accreditation Compliance :
• Support and manage activities related to URAC accreditation, ensuring clinical operations meet quality and compliance standards
• Stay updated on regulatory changes and ensure processes align with industry standards
• What you need :
• Bachelors degree in Pharmacy required
• Advanced degree (PharmD, MBA) preferred
• Active and unrestricted Pharmacist license, not state specific
• 5 years of experience in clinical operations, coding management, or related roles
• 3 years in a leadership position preferred
• 3 years of experience in pharmacy benefit management (PBM) preferred
• Proven expertise in managing clinical benefit setups, coding processes, and regulatory compliance
• Proficiency with clinical coding systems and platforms
• Strong analytical and problem-solving skills, with experience in testing and validating benefit setups
• Excellent project management skills, including the ability to lead cross-functional teams and manage escalations
• Familiarity with Medispan or First Data Bank terminology preferred
• Proficiency in Microsoft Office Suite
• Deep understanding of ACA / preventive drug list maintenance and URAC accreditation requirements
• Ability to work collaboratively with cross-functional teams
• Willingness and ability to travel (up to 10%)

What you get :

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.

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