Director, Utilization Management

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.

Position Summary:

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.

What you will do:

Strategic Leadership and Enterprise Impact:

• 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

Operational Oversight and Process Excellence:

• 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