Remote Anthem Utilization Review Nurse Jobs in Renton, WA

The Clinical Domain Project Manager plans, coordinates, and delivers pharmacy clinical initiatives within a Medicaid, pharmacy benefit management (PBM), and healthcare payer environment. This role serves as the primary liaison between business stakeholders, clinical pharmacists, operational teams, technology teams, and external partners to ensure successful implementation of pharmacy clinical solutions and regulatory requirements. Assigned projects span drug coverage administration, Preferred Drug List (PDL) management, prior authorization, utilization management, drug utilization review, clinical criteria configuration, and pharmacy system implementations, with accountability for project governance, schedule management, stakeholder communications, risk management, and delivery of business outcomes. This is a fully remote, full time engagement with an anticipated duration of ten months and an immediate start. No travel is required, and a background check must be successfully completed prior to onboarding.

Must be eligible to work in the United States. No sponsorships are available at this time.

Essential Duties:

Project Leadership and Delivery:

• Leads pharmacy clinical projects through initiation, planning, execution, monitoring, and closure
• Develops and maintains integrated project plans, schedules, milestones, dependencies, and deliverables
• Facilitates requirements gathering, design reviews, solution validation, testing, and implementation activities
• Coordinates cross-functional teams across clinical, operational, technical, and business workstreams
• Manages project budgets, scope, schedule, risks, issues, assumptions, and dependencies
• Supports implementation and enhancement of drug coverage administration, Preferred Drug List (PDL) management, prior authorization (PA) programs, electronic prior authorization (ePA), and drug utilization review (DUR)
• Ensures clinical program requirements are accurately translated into system and operational solutions

Stakeholder Engagement:

• Serves as primary point of contact for client, clinical, and internal project stakeholders
• Facilitates decision-making discussions and executive governance meetings
• Communicates project status, risks, issues, and mitigation strategies to leadership
• Builds collaborative relationships with pharmacy directors, clinical pharmacists, business analysts, product teams, and external vendors

Compliance and Regulatory Oversight:

• Ensures project deliverables comply with federal and state Medicaid requirements
• Supports readiness for audits, regulatory reviews, and contractual reporting obligations
• Coordinates implementation efforts involving the Centers for Medicare and Medicaid Services (CMS), Medicaid agencies, pharmacy benefit managers (PBMs), and healthcare partners as applicable
• Maintains traceability between business requirements, design decisions, testing results, and implemented solutions

Vendor and Partner Coordination:

• Coordinates activities with PBMs, pharmacy system vendors, clinical review organizations, and state stakeholders
• Manages integration and dependency tracking across external partners
• Facilitates issue resolution and escalation management to meet project objectives

Implementation and Transition:

• Leads implementation readiness reviews and go-live planning activities
• Coordinates training, deployment, cutover, and stabilization efforts
• Develops implementation plans, communication strategies, and transition-to-operations procedures
• Supports continuous improvement initiatives and lessons-learned activities

Requirements

Required Skills:

• Demonstrated success leading large-scale healthcare or pharmacy benefit management (PBM) implementations
• Experience managing multiple workstreams and vendors simultaneously
• Experience leading end-to-end lifecycle activities from project startup through post go-live support
• Experience with Preferred Drug List (PDL) administration
• Experience with prior authorization (PA) programs
• Experience with electronic prior authorization (ePA) and drug utilization review (DUR)
• Experience with clinical policy administration and utilization management initiatives
• Expert-level schedule performance management using Microsoft Project
• Deliverable management, including Medicaid deliverable oversight
• Risks, actions, issues, and decisions (RAID) management
• Project controls based on the Project Management Body of Knowledge (PMBOK)
• Cross-domain coordination across claims, provider, member, clinical, rebate, and portal functions

Education and Experience:

• Seven or more years of project management experience
• Seven or more years of experience supporting Pharmacy Benefit Management (PBM) Medicaid programs
• Project Management Professional (PMP) certification preferred, not required

Physical Requirements & Environmental Conditions: An employee must meet these physical demands to successfully perform the essential functions of this job. Employee is regularly required to talk or hear, sit, stand, and utilize technology tools such as a laptop computer for extended periods of time. Specific vision abilities include close vision and the ability to adjust focus. This position requires the ability to occasionally lift up to 20 lbs. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Briljent is a solutions-based company. Solutions come from creative ideas; ideas come from being creative with differences. Briljent believes diversity and inclusion are critical to the success of the company. Employment at Briljent is based on merit and professional qualifications. We do not discriminate against any employee or applicant because of race, creed, color, religion, gender, sexual orientation, national origin, disability, age, veteran status, marital status or any other basis protected by federal, state or local law, regulation or ordinance.

Benefits

• Health Care Plan (Medical, Dental & Vision)
• Retirement Plan (401k, IRA)
• Life Insurance (Basic, Voluntary & AD&D)
• Paid Time Off (Vacation, Sick & Public Holidays)
• Short Term & Long Term Disability
• Work From Home
• Wellness Resources