Health Services Professional, RN
About the position
As a Regulatory Health Services Professional, you will help establish and implement processes to ensure utilization management (UM) programs are compliant and supportive of regulatory and PBM pharmacy guidelines. Knowledge of utilization management interventions including prior authorization, step therapy, quantity limits and formulary exceptions is required. Additionally, you will work in a matrix relationship with business partners and regulatory affairs to assist in identifying the impact of new regulatory guidance and requirements on UM criteria. Knowledge of regulations impacting UM for Medicare, Medicaid and Exchange clients is preferred. It may be necessary to create regulatory content for all business segments (Commercial, Medicare, Medicaid and Marketplace) with the ability to be consultative to product owners, account management and clients. This is a hybrid role, based out of our Buffalo Grove, IL, Pittsburgh, PA, or NYC office locations.
Responsibilities
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- Requirements
- Active Registered Nurse (RN) Licensure in good standing ,
- 5+ years of healthcare experience ,
- Ability to collaborate and communicate with members of an interdisciplinary care team ,
- Effective problem solving, decision-making, and prioritization skills ,
- Strong PC skills: Office 365 with ability to quickly learn new applications as needed
- Nice-to-haves
- Experience reviewing and interpreting laws, rules, and regulations ,
- Knowledge of PBM and benefit design preferred ,
- 2+ years of Managed Care or PBM experience
- Benefits
- Affordable medical plan options ,
- 401(k) plan (including matching company contributions) ,
- Employee stock purchase plan ,
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching ,
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility
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