Product Manager, Clinical & Authorization

Position Summary:

The Product Manager – Clinical & Authorization Platforms owns the strategy, roadmap, and execution of RxSense’s clinical rules infrastructure and prior authorization capabilities. This role is responsible for the platform functionality that enables clients to configure, operationalize, and scale their clinical policies and utilization management programs.

RxSense serves enterprise PBMs and healthcare organizations that define their own clinical criteria. The Product Manager ensures those client-defined rules—such as prior authorization requirements, step therapy protocols, quantity limits, refill-too-soon controls, and specialty restrictions—are accurately translated into configurable system logic and efficient workflows within the RxSense platform.

This role balances flexibility and standardization, ensuring the platform supports complex client configurations while maintaining performance, scalability, automation, and a high-quality provider and member experience.

To Be Successful in This Role, the Ideal Candidate Will

• Develop deep expertise in prior authorization, utilization management, and clinical edit frameworks.
• Understand how PBM-defined clinical criteria must be operationalized within configurable systems.
• Think holistically across adjudication engines, accumulators, benefit design, network configurations, and hierarchy-based (OCAG) inheritance models.
• Translate client requirements into scalable product capabilities rather than one-off custom solutions.
• Balance automation and human review workflows to optimize efficiency without compromising clinical controls.
• Use performance data to continuously refine rule precision, reduce false positives, and minimize provider/member friction.
• Demonstrate strong systems thinking, recognizing how clinical rules interact across the broader RxSense platform architecture.

Expectations

Clinical Rules Infrastructure Ownership

• Own the end-to-end clinical rules framework within the platform.
• Ensure accurate implementation of client-defined clinical criteria into configurable system logic.
• Design scalable configuration models that support multiple enterprise clients without degrading performance.
• Maintain consistency between formulary integration, clinical edits, and authorization workflows.

Authorization Workflow Strategy

• Lead the evolution of electronic PA submission, review, approval/denial, exception, and appeals processes.
• Improve authorization turnaround times and automation rates.
• Ensure determination messaging is clear, actionable, and configurable to meet client needs.

Platform Governance & Quality

• Maintain traceability between client requirements, system configuration, and adjudication outcomes.
• Partner with internal clinical SMEs and client stakeholders to implement updates tied to drug launches, safety changes, and rule adjustments.
• Define and monitor KPIs that measure workflow efficiency, automation, and rule effectiveness.

Product Leadership & Execution

• Own and prioritize the clinical platform backlog based on enterprise scalability, client impact, and operational value.
• Develop detailed feature specifications with measurable outcomes and acceptance criteria.
• Collaborate closely with engineering, architecture, clinical SMEs, operations, and commercial teams.
• Support client implementations and platform rollouts tied to clinical functionality.

Desired Skills & Experience

• 4+ years of experience in a PBM, health plan, or healthcare technology environment with direct exposure to prior authorization and utilization management workflows.
• 4+ years working within agile product teams, healthcare operations, or related environments.
• Experience working with clinical rules engines, decision support systems, or authorization platforms.
• Strong understanding of how clinical criteria are operationalized within adjudication and workflow systems.
• Familiarity with ePA standards and healthcare interoperability (e.g., NCPDP SCRIPT, FHIR).
• Experience operating within agile product environments and managing roadmaps/backlogs in JIRA (or similar tools).
• Proven ability to communicate effectively across engineering, clinical, operational, and executive stakeholders.
• Strategic mindset with the ability to connect platform capabilities to client needs and business growth objectives.

Salary Range: 100,000 - 149,000