Utilization Management Specialist Jobs in New York
Utilization Management Specialist jobs in New York are among the most active in the country, with strong demand from health plans, hospital systems, and managed care organizations at every level from entry-level reviewer through senior clinical lead. Most hiring is concentrated in New York City, Albany, and Buffalo, where major employers such as EmblemHealth, Northwell Health, and MetroPlus Health Plan maintain large UM departments. Behavioral health, Medicare Advantage, and complex case coordination are the most consistently in-demand specialty areas. Find a role that fits below and apply directly.
Find JobsOverview
Showing 5 of 11+ Utilization Management Specialist jobs
ABOUT THE ROLE:
Our PBM goal is to help clients better manage pharmacy spend to make drugs more affordable for their employees and dependents. Rightway is responsible for designing, building, and operating a new-to-the-world PBM model based on our core tenets: fairness & transparency, unlocking the supply chain, supporting the physician-patient relationship, and utilizing navigation to empower consumers. This role will assist UM leadership in delivering on our UM strategy and actively work UM cases.
The Clinical Pharmacist, Utilization Management is a member of the Rightway PBM Clinical Operations team. Our pharmacy benefit management (PBM) offering represents an important growth area for Rightway. Helping clients better manage pharmacy spend to make drugs more affordable for their employees and dependents is critical to their business sustainability. RightwayRx is responsible for designing, building and operating a new-to-the-world PBM model base on our core tenets: fairness & transparency, unlocking the supply chain, supporting the physician-patient relationship, and utilizing navigation to empower consumers
WHAT YOU'LL DO:
- Support all lines of business via reviewing utilization management requests for coverage that are clinically appropriate and cost effective
- Continual review of UM operational processes to ensure effective and compliant delivery of PBM services to our clients.
- Coordinate with Pharmacy technicians, Pharmacists, and/or Medical Directors on UM activities
- Ensure cases are reviewed in accordance with State and/or Federal guidelines including turnaround time requirements
- As needed, discuss clinical strategy and decision rationale with prescribers
- Participate in the quality review and inter-rater reliability processes
- Supports P&T process including the development of therapeutic class/drug monographs as needed
- Research and develop therapy-specific clinical policies and utilization management programs such as Prior Authorization, Step Therapy, Quantity Limit, and/or Coverage Determination programs
- Support Clinical Operations leadership and coordinate with Pharmacy Navigation team as needed
WHO YOU ARE:
- Education level: Pharmacy Degree Required, PharmD preferred.
- Work experience: 1 year experience coordinating medication selection with prescribers and their care teams. Preferred: 1-3+ years of managed care (PBM or health plan) prior authorization experience
- Pharmacist license in good standing in state of residence. Willingness to achieve and maintain licensure in multiple states (if needed)
- Available to work 40 hours/week. Core operating hours are weekdays within 8 am Eastern Time and 8 pm Eastern Time, but may be required to work evening and/or weekend shifts in the future as Rightway grows. On call approximately once every two months.
- Important characteristics of ideal candidate: Detail-oriented, intellectually and clinically curious, good listener, empathetic, ability to challenge status quo, values exemplar
- Specific skills needed for job: Great pharmacy benefit knowledge, effective & creative problem-solver, ability to prioritize and manage through change. Solid communication skills, ability to lead projects and influence others even without direct reporting line ownership
BASE SALARY: $120,000-125,000 annually, in addition to bonus and equity
Compensation offered will be determined by geographic location, experience, and qualifications.
CYBERSECURITY AWARENESS NOTICE
In response to ongoing and industry-wide fraudulent recruitment activities (i.e., job scams), Rightway wants to inform potential candidates that we will only contact them from the @rightwayhealthcare.com email domain. We will never ask for bank details or deposits of any kind as a condition of employment.
ABOUT RIGHTWAY:
Rightway is on a mission to harmonize healthcare for everyone, everywhere. Our products guide patients to the best care and medications by inserting clinicians and pharmacists into a patient's care journey through a modern, mobile app. Rightway is a front door to healthcare, giving patients the tools they need along with on-demand access to Rightway health guides, human experts that answer their questions and manage the frustrating parts of healthcare for them.
Since its founding in 2017, Rightway has raised over $300mm from investors including Khosla Ventures, Thrive Capital, Francisco Partners, and Tiger Global. We're headquartered in New York City, with satellite offices in Denver and Dallas. Our clients rely on us to transform the healthcare experience, improve outcomes for their teams, and decrease their healthcare costs.
HOW WE LIVE OUR VALUES TO OUR TEAMMATES:
We're seeking those with passion for healthcare and relentless devotion to our goal. We need team members that embody our core values:
1) We are human, first
Our humanity binds us together. We bring the same empathetic approach to every individual we engage with, whether it be our members, our clients, or each other. We are all worthy of respect and understanding and we engage in our interactions with care and intention. We honor our stories. We listen to—and hear—each other, we celebrate our differences and similarities, we are present for each other, and we strive for mutual understanding.
2) We redefine what is possible
We always look beyond the obstacles in front of us to imagine new solutions. We approach our work with inspiration from other industries, other leaders, and other challenges. We use ingenuity and resourcefulness when faced with tough problems.
3) We debate then commit
We believe that a spirit of open discourse is part of a healthy culture. We understand and appreciate different perspectives and we challenge our assumptions. When working toward a decision or a new solution, we actively listen to one another, approach it with a "yes, and" mentality, and assume positive intent. Once a decision is made, we align and champion it as one team.
4) We cultivate grit
Changing healthcare doesn't happen overnight. We reflect and learn from challenges and approach the future with a determination to strive for better. In the face of daunting situations, we value persistence. We embrace failure as a stepping stone to future success. On this journey, we seek to act with guts, resilience, initiative, and tenacity.
5) We seek to delight
Healthcare is complicated and personal. We work tirelessly to meet the goals of our clients while also delivering the best experience to our members. We recognize that no matter the role or team, we each play a crucial part in our members' care and take that responsibility seriously. When faced with an obstacle, we are kind, respectful, and solution-oriented in our approach. We hold ourselves accountable to our clients and our members' success.
Rightway is proud to be an Equal Opportunity Employer that believes in the strength of diverse thought, beliefs, backgrounds, and education. We foster an inclusive culture where differences are celebrated to drive the best business decisions possible. We do not discriminate on any basis protected by applicable law. All employment decisions are based on merit, qualifications, need, and performance.
ABOUT THE ROLE:
Our PBM goal is to help clients better manage pharmacy spend to make drugs more affordable for their employees and dependents. Rightway is responsible for designing, building, and operating a new-to-the-world PBM model based on our core tenets: fairness & transparency, unlocking the supply chain, supporting the physician-patient relationship, and utilizing navigation to empower consumers. This role will assist UM leadership in delivering on our UM strategy and actively work UM cases.
The Clinical Pharmacist, Utilization Management is a member of the Rightway PBM Clinical Operations team. Our pharmacy benefit management (PBM) offering represents an important growth area for Rightway. Helping clients better manage pharmacy spend to make drugs more affordable for their employees and dependents is critical to their business sustainability. RightwayRx is responsible for designing, building and operating a new-to-the-world PBM model base on our core tenets: fairness & transparency, unlocking the supply chain, supporting the physician-patient relationship, and utilizing navigation to empower consumers
WHAT YOU'LL DO:
- Support all lines of business via reviewing utilization management requests for coverage that are clinically appropriate and cost effective
- Continual review of UM operational processes to ensure effective and compliant delivery of PBM services to our clients.
- Coordinate with Pharmacy technicians, Pharmacists, and/or Medical Directors on UM activities
- Ensure cases are reviewed in accordance with State and/or Federal guidelines including turnaround time requirements
- As needed, discuss clinical strategy and decision rationale with prescribers
- Participate in the quality review and inter-rater reliability processes
- Supports P&T process including the development of therapeutic class/drug monographs as needed
- Research and develop therapy-specific clinical policies and utilization management programs such as Prior Authorization, Step Therapy, Quantity Limit, and/or Coverage Determination programs
- Support Clinical Operations leadership and coordinate with Pharmacy Navigation team as needed
WHO YOU ARE:
- Education level: Pharmacy Degree Required, PharmD preferred.
- Work experience: 1 year experience coordinating medication selection with prescribers and their care teams. Preferred: 1-3+ years of managed care (PBM or health plan) prior authorization experience
- Pharmacist license in good standing in state of residence. Willingness to achieve and maintain licensure in multiple states (if needed)
- Available to work 40 hours/week. Core operating hours are weekdays within 8 am Eastern Time and 8 pm Eastern Time, but may be required to work evening and/or weekend shifts in the future as Rightway grows. On call approximately once every two months.
- Important characteristics of ideal candidate: Detail-oriented, intellectually and clinically curious, good listener, empathetic, ability to challenge status quo, values exemplar
- Specific skills needed for job: Great pharmacy benefit knowledge, effective & creative problem-solver, ability to prioritize and manage through change. Solid communication skills, ability to lead projects and influence others even without direct reporting line ownership
BASE SALARY: $120,000-125,000 annually, in addition to bonus and equity
Compensation offered will be determined by geographic location, experience, and qualifications.
CYBERSECURITY AWARENESS NOTICE
In response to ongoing and industry-wide fraudulent recruitment activities (i.e., job scams), Rightway wants to inform potential candidates that we will only contact them from the @rightwayhealthcare.com email domain. We will never ask for bank details or deposits of any kind as a condition of employment.
ABOUT RIGHTWAY:
Rightway is on a mission to harmonize healthcare for everyone, everywhere. Our products guide patients to the best care and medications by inserting clinicians and pharmacists into a patient's care journey through a modern, mobile app. Rightway is a front door to healthcare, giving patients the tools they need along with on-demand access to Rightway health guides, human experts that answer their questions and manage the frustrating parts of healthcare for them.
Since its founding in 2017, Rightway has raised over $300mm from investors including Khosla Ventures, Thrive Capital, Francisco Partners, and Tiger Global. We're headquartered in New York City, with satellite offices in Denver and Dallas. Our clients rely on us to transform the healthcare experience, improve outcomes for their teams, and decrease their healthcare costs.
HOW WE LIVE OUR VALUES TO OUR TEAMMATES:
We're seeking those with passion for healthcare and relentless devotion to our goal. We need team members that embody our core values:
1) We are human, first
Our humanity binds us together. We bring the same empathetic approach to every individual we engage with, whether it be our members, our clients, or each other. We are all worthy of respect and understanding and we engage in our interactions with care and intention. We honor our stories. We listen to—and hear—each other, we celebrate our differences and similarities, we are present for each other, and we strive for mutual understanding.
2) We redefine what is possible
We always look beyond the obstacles in front of us to imagine new solutions. We approach our work with inspiration from other industries, other leaders, and other challenges. We use ingenuity and resourcefulness when faced with tough problems.
3) We debate then commit
We believe that a spirit of open discourse is part of a healthy culture. We understand and appreciate different perspectives and we challenge our assumptions. When working toward a decision or a new solution, we actively listen to one another, approach it with a "yes, and" mentality, and assume positive intent. Once a decision is made, we align and champion it as one team.
4) We cultivate grit
Changing healthcare doesn't happen overnight. We reflect and learn from challenges and approach the future with a determination to strive for better. In the face of daunting situations, we value persistence. We embrace failure as a stepping stone to future success. On this journey, we seek to act with guts, resilience, initiative, and tenacity.
5) We seek to delight
Healthcare is complicated and personal. We work tirelessly to meet the goals of our clients while also delivering the best experience to our members. We recognize that no matter the role or team, we each play a crucial part in our members' care and take that responsibility seriously. When faced with an obstacle, we are kind, respectful, and solution-oriented in our approach. We hold ourselves accountable to our clients and our members' success.
Rightway is proud to be an Equal Opportunity Employer that believes in the strength of diverse thought, beliefs, backgrounds, and education. We foster an inclusive culture where differences are celebrated to drive the best business decisions possible. We do not discriminate on any basis protected by applicable law. All employment decisions are based on merit, qualifications, need, and performance.
See All 11 Utilization Management Specialist Jobs in New York
Find roles in New York that match your experience and apply in just a few clicks.
Find JobsUtilization Management Specialist Jobs by City in New York
Where New York roles are concentrated, by current openings.
Utilization Management Specialist Job Market in New York
A snapshot from current New York openings, updated as new roles post.
Who's Hiring
Top Industries Hiring
- Insurance
What New York Employers Look For
The qualifications that appear most often in utilization management specialist jobs across New York.
- Active New York RN license or licensed clinical social worker credential required
- Two or more years of clinical or managed care utilization review experience preferred
- Working knowledge of InterQual or Milliman care guidelines for medical necessity determinations
- Familiarity with New York State Department of Health regulations and Medicaid managed care requirements
- Proficiency with electronic health records and utilization management platforms such as Jiva or Facets
- Strong written communication skills for producing clear, timely clinical documentation and appeal responses
Utilization Management Specialist Jobs in New York: Frequently Asked Questions
How do you become a utilization management specialist in New York?
Most utilization management specialist roles in New York require an active clinical license, typically a New York State Registered Nurse license issued by the New York State Education Department or a licensed clinical social worker credential from the same board. Employers generally expect a bachelor's degree in nursing, social work, or a related health field, plus hands-on clinical experience. Some positions accept licensed practical nurses or certified case managers as an alternative pathway into entry-level reviewer roles.
Which companies hire utilization management specialists in New York?
Employers hiring utilization management specialists in New York right now include MetroPlusHealth, Rightway Healthcare, and Oscar Health, based on current listings on Migrate Mate as of October 2026. New York's dense concentration of health plans, hospital-owned insurance products, and Medicaid managed care organizations means consistent demand from both large systems and regional payers operating under New York State Department of Health oversight.
Which New York cities have the most utilization management specialist jobs?
New York, New York State, and Glens Falls account for the largest share of utilization management specialist openings in New York. New York City leads because of its concentration of major health plans, managed care organizations, and large academic medical centers, while Albany draws openings tied to state agency contracts and regional health plans, and Buffalo anchors demand in western New York through large regional health systems and insurer regional offices.
Are there remote utilization management specialist jobs in New York?
Yes, and more than most clinical fields, since utilization review is largely documentation and phone-based work that does not require physical patient contact. About 100% of utilization management specialist openings tied to New York are remote or hybrid as of October 2026, reflecting the role's suitability for distributed teams. Prior authorization review and telephonic case management are the functions most commonly offered on a fully remote basis by New York employers.
How can I get hired as a utilization management specialist in New York with little or no experience?
The most realistic entry path is a lateral move from a direct clinical role, since New York health plans and managed care organizations such as EmblemHealth and Healthfirst regularly bring on staff with bedside nursing or hospital discharge planning backgrounds for entry-level prior authorization reviewer positions. Case management coordinator and care transitions roles at New York hospital systems also serve as a direct bridge. Earning a certified case manager credential strengthens any application and is weighted heavily by New York managed care employers.
Where can I find and apply to utilization management specialist jobs in New York?
You can find and apply to utilization management specialist jobs in New York on Migrate Mate, which lists current openings from New York employers. Search the listings, find roles that match your experience and preferred location, and apply directly to the ones that fit.
See All 11 Utilization Management Specialist Jobs in New York
Find roles in New York that match your experience and apply in just a few clicks.
Find Jobs