• Interpret formulary and clinical program performance data — using available dashboards and reporting tools — to identify trends and opportunities. • Translate data findings into clear, actionable clinical recommendations for clinical strategy leadership. • Support RFI and RFP submissions with data-driven clinical insights. • Actively incorporate AI tools into your daily workflow — from literature review and PA criteria drafting to formulary documentation and data summarization. • Identify opportunities where AI can streamline clinical operations tasks and help the team scale effectively. • Contribute to Rightway's evolving approach to AI adoption in clinical work; share learnings and best practices with the broader team. • Leverage AI-assisted tools to synthesize clinical literature, draft policy language, and accelerate research tasks. • Support the development, maintenance, and updating of Rightway formularies, including standard and custom drug lists. • Assist in formulary coding and collaborate with the claims platform team to ensure accuracy and functionality. • Participate in formulary testing, validation, and ongoing quality review. • Contribute to Pharmacy & Therapeutics (P&T) Committee meetings with drug evaluations, literature summaries, and formulary performance updates. • Help explore and support the implementation of non-traditional formulary designs beyond tier-based structures. • Develop, maintain, and update prior authorization criteria and clinical coverage policies. • Review PA criteria against current clinical evidence, payer benchmarks, and regulatory standards. • Support clinical reviews and provide recommendations on complex or escalated PA cases, as needed. • Assist in communicating PA criteria changes to operational teams, clients, and members. • Partner with Director of Utilization Management on the implementation and operations of clinical strategy. • Partner with Product, Data & Insights, Cost of Goods, and Client Operations teams to support formulary and clinical program implementation. • Provide clinical support to operational teams and clients during implementation and ongoing account management. • Facilitate communication and education to clients, members, and internal staff on clinical topics and formulary changes.

• Coordinate and process medication refills, including data entry and claim adjudication • Place outbound refill calls and assist patients through the refill request • Respond to and resolve inbound patient and provider inquiries • Clarify prescription orders with pharmacists or clinical staff • Maintain and update patient and prescription data in software systems • Spot trends, recommend improvements, and support process-improvement initiatives • Partner with cross-functional teams to deliver a seamless patient experience • Maintain confidentiality and uphold high-quality service standards

• Performs telephonic comprehensive medication reviews • Updates patient profiles based on information gathered during the review • Reviews any Drug Therapy Problems to optimize patient’s drug therapy and minimize the potential for adverse drug reactions • Works with multidisciplinary team to enhance and develop our MedPro software. • Completes at least (2) two CMR’s per hour • Assists Clinical team in meeting proficiency and quality goals • Utilizes client formulary information and member specific benefits to guide appropriate medication recommendations • Maintains current on emerging trends that will educate clinical team, physicians and other prescribers

Role Description This position is available to work from home from within the Sutter Health Northern California footprint. Responsible for performing the appropriate processes to verify patient eligibility, coordinate benefits, ensure insurance coverage, and determine if prior authorization is needed for said order. If needed, obtains authorization and documents in the patient electronic medical record. Facilitates responses to patient inquiries regarding authorizations within turnaround standards. Qualifications - HS Diploma or GED - 1 year recent relevant experience Requirements - Medical terminology knowledge - Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS)/International Classification of Diseases (ICD)-9 coding knowledge - Knowledge of medical terminology/anatomy - Ability to exercise discretion and make independent judgments, seeking review when decisions represent significant departure from established guidelines - Knowledge of Microsoft Office programs including Excel, Word or similar programs - Ability to maintain composure during challenging interpersonal interactions - Active listening skills; including interpersonal skills and telephone communication - Organizational skills with attention to detail and follow-up Benefits - Eligible positions include a comprehensive benefits package Company Description Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans. Pay Range is $27.50 to $34.37 / hour. The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health’s comprehensive total rewards program.