Utilization Review Nurse Compact License Jobs in Puerto Rico

Regular

Exempt

Responsible for overseeing the implementation, administration, and continuous improvement of clinical and quality pharmacy programs within the Pharmacy Department. These programs include Medication Therapy Management (MTM), Drug Management Programs (DMP), CMS STARS initiatives, pharmacy utilization programs, academic detailing, member education activities, and the operational management of regulatory grievances and appeals. Works closely with pharmacy and clinical leadership to ensure programs are executed effectively, remain compliant with regulatory requirements, support population health objectives, and contribute to organizational goals. Oversees Pharmacy Account Management operations, collaborates with cross-functional business partners, manages vendor relationships, and serves as a clinical pharmacy resource for internal stakeholders.

• Manage the implementation and operations of Clinical Services, Pharmacy Utilization, and Account Management programs, ensuring compliance with federal, state, and local regulations, as well as organizational policies and procedures.
• Support the development, execution, and ongoing enhancement of clinical pharmacy programs, ensuring alignment with departmental objectives, quality standards, and member needs.
• Oversee delegated vendor activities related to Medication Therapy Management Program (MTMP), Integrated Diabetes Program, Specialty Pharmacy Interventions, Designated Medical/Prescribing Practitioner (DMP/DPP), and Centers for Medicare and Medicaid Services (CMS) STARS measures, monitoring performance and compliance with contractual and regulatory requirements.
• Coordinate the implementation and monitoring of clinical and quality pharmacy programs to ensure adherence to CMS, National Committee for Quality Assurance (NCQA), and other applicable regulatory standards. Identify opportunities for improvement and recommend corrective actions as needed.
• Collaborate with other internal departments to ensure effective integration of pharmacy programs with broader care management, quality improvement, and population health initiatives.
• Manage the Pharmacy Account Management function, ensuring timely resolution of client and internal inquiries, operational effectiveness, and delivery of high-quality service across all lines of business.
• Monitor program performance metrics, quality outcomes, operational effectiveness, and regulatory compliance indicators. Prepare reports and recommendations for pharmacy leadership to support decision-making and continuous improvement efforts.
• Represent the Department in operational meetings, client discussions, vendor reviews, and cross-functional committees. Present program results, operational updates, and compliance activities to leadership and stakeholders.
• Assist in budget planning and resource management for clinical and quality pharmacy programs. Monitor expenses and support cost-effective program administration while maintaining quality and compliance standards.
• Oversee the review process for pharmacy communications, member materials, and regulatory documentation to ensure accuracy, compliance, and adherence to organizational standards.
• Supervises, monitors, trains, evaluates, and corrects personnel, among others to comply with his/her role as a supervisor, to ensure that his/her personnel fulfill their work plan and comply with their essential functions, and that they behave following the policies, standards, norms, and procedures of the Company.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws, as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

Education and Experience: Doctor of Pharmacy (PharmD) or equivalent degree required. At least eight (8) years of progressive leadership experience in managed care pharmacy, clinical program development, or pharmacy quality management, with demonstrated success in applying quality performance metrics. At least five (5) years of experience supervising personnel.

Certifications / Licenses: A valid License and Registration of a Pharmacist & Association of Pharmacists of Puerto Rico is required. Other: In-depth knowledge of CMS, NCQA, HEDIS, STARS measures, and state/federal healthcare regulations. Proficiency in pharmacy benefit systems, clinical data analytics, and population health strategies.

Spanish – Advanced (comprehensive, writing, and verbal)

English – Advanced (comprehensive, writing, and verbal)

“We are an Equal Employment Opportunity Employer and takeAffirmative Action to recruit Protected Veterans and Individuals with Disabilities.”

MCS Healthcare Holdings, LLC. (MCS)is an Equal Employment Opportunity Employer and take
Affirmative Action to recruit Protected Veterans and Individuals with Disabilities. MCS is a participating E-Verify employer.