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Job Description:

Summary:

This role provides strategic, clinical, and operational leadership for the Candesa Utilization Management (UM) program, driving innovation and ensuring strong alignment with organizational goals. As the senior clinical authority for Candesa UM, this position sets the vision for how clinical criteria, benefit strategies, and UM workflows are designed, governed, and executed. This position also serves as a key clinical advisor for external clients including sales support, guiding clients through implementation, and representing the UM program with credibility and expertise. Through strong cross‑functional leadership and clinical stewardship, the role ensures the Candesa UM program delivers high‑quality, accurate, and consistent utilization management outcomes that meet organizational and client goals.

Essential Accountabilities:

Lead the strategic planning, execution, and business objectives for the Candesa Utilization Management (UM) product.
Serve as the clinical and operational subject matter expert responsible for execution of operational UM workflows within the Candesa platform.
Own the clinical design and configuration of UM workflows within the Candesa platform.
Oversee configuration of benefit designs, coverage rules, and clinical criteria within the platform.
Ensure clinical criteria used in UM reviews align with FDA labeling, national treatment guidelines, and payer coverage policies.
Oversee maintenance of clinical decision logic used in prior authorization workflows to ensure alignment with the above.
Drive short- and long-term product development and enhancements by collaborating with Pharmacy Solutions, Compliance, Legal, Sales, Marketing, Finance, Provider Contracting, and AD&T.
Provide clinical oversight of technical implementation work, ensuring utilization management workflows accurately reflect policy intent and clinical standards.
Partner with UM operations, technology, and clinical policy teams to ensure clinical criteria are accurately configured and operationalized.
Identify operational barriers and align cross-functional teams to meet quality standards, project timelines, and organizational objectives.
Support the Sales team as the clinical subject matter expert, partnering with external clients throughout sales, contracting, and implementation stages.
Act as a primary liaison for external clients, providing clinical and operational expertise to ensure customer satisfaction and effective program implementation.
Serve as a liaison between clinical teams, operational teams, and technology partners to ensure accurate and aligned implementation.
Oversee implementation, updates, and maintenance of custom pharmacy benefit designs for employer groups, ensuring benefit structures align with UM strategies and formulary management.
Maintain a structured repository of custom benefit designs by client including design components, historical updates, and change requests.
Monitor utilization trends and recommend clinical or operational program enhancements to confirm and improve effectiveness of UM programs.
Analyze utilization and operational data to identify workflow inefficiencies and recommend process improvements.
Support client implementations by providing clinical expertise regarding UM criteria, coverage strategies, and workflow design.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and embodying the Lifetime Way values and beliefs.
Maintain high regard for member privacy in accordance with corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Perform other duties as assigned by management.

Minimum Qualifications:

Unrestricted NYS Licensed Pharmacist.
Pharm.D. In lieu of a Pharm.D., a Bachelors in Pharmacy is required.
Minimum of 6 years' experience in an organized health plan or pharmacy benefit manager setting required.
Prior experience supervising or leading people, projects and/or teams.
Excellent project management skills including the ability to manage multiple complex projects within time and budget constraints.
Ability to serve as a knowledgeable liaison regarding the Candesa UM product both externally and internally.
Excellent analytical and business planning skills.
Excellent written and oral communication skills.
Remains current on evolving market dynamics within the industry and regulatory environment. Ties this information to Candesa's mission and ensures awareness among key business partners.

Physical Requirements:

Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
Ability to lift, carry, push, or pull 15 pounds or less.
Manual dexterity including fine finger motion required.
Repetitive motion required.
The ability to hear, understand, and speak clearly while using a phone, with or without a headset.

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In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

E9 Min: $110,0093 - Max: $198,168

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

With about 4,000 employees, 31 counties, and serving the needs of over 1.5 million members, you can imagine the gamut of skills it takes to keep our organization growing and our members flourishing. As an internal job seeker, this means growth and development in many directions, divisions, and roles.

Take a look at information regarding our hiring process here.

https://lifethc.sharepoint.com/sites/HumanCapitalManagement/SitePages/Talent-Acquisition-%26-Onboarding.aspx#hiring-process

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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