Prior Authorization Systems Pharmacist
About Judi Health
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:
- Capital Rx: A public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers.
- Judi Health™: Offering full-service health benefit management solutions to employers, TPAs, and health plans.
- Judi®: The industry’s leading proprietary Enterprise Health Platform (EHP), consolidating all claim administration-related workflows in one scalable, secure platform.
To learn more, visit www.judi.health.
Position Summary
Responsible for the design, configuration, and quality assurance of prior authorization (PA) criteria, including decision trees, authorization parameters, and member/provider communications within the PA system.
Position Responsibilities
- Build decision trees and question sets from PA criteria for prior authorization review.
- Perform comprehensive quality control (QC) review of decision trees, questionnaires, and authorization logic to ensure alignment with clinical intent, regulatory requirements, and business rules.
- Conduct quality assurance (QA) validation of configured criteria and decision paths, including scenario-based testing to confirm expected outcomes across approval and denial pathways.
- Ensure PA questionnaires are configured with the appropriate authorization parameters for approval.
- Collaborate with external clients for delegated clinical PA systems services.
- Manage setup, contracting, and relationships with prior authorization external vendors.
- Work with Director, Utilization Management on other responsibilities, projects, and initiatives as needed.
- Adhere to the Capital Rx Code of Conduct including reporting of noncompliance.
- Map of prior authorization member and prescriber letter templates in the prior authorization system.
- Perform QC and QA review of member and prescriber letter templates to ensure accuracy, completeness, regulatory compliance, and alignment with configured decision logic.
- Validate that denial rationales, approval language, and conditional messaging accurately reflect clinical criteria and system outputs.
- Develop and maintain policies and procedures for creation and maintenance of clinical criteria questions and letter templates.
- Establish and maintain QA/QC standards, documentation, and audit processes for decision trees, criteria configurations, and letter templates.
- Identify PA reporting needs and collaborate with appropriate stakeholders to develop reports.
- Attend formulary meetings and presentations as needed to stay abreast of all pertinent new information and changes.
- Collaborate with external clients for delegated clinical PA systems services.
- Manage setup, contracting, and relationships with prior authorization external vendors.
- Work with Director, Utilization Management on other responsibilities, projects, and initiatives as needed.
- Adhere to the Capital Rx Code of Conduct including reporting of noncompliance.
Minimum Qualifications
- Active, unrestricted, pharmacist license required.
- 3+ years health plan or PBM pharmacy experience required.
- Strong clinical background and presentation skills required.
- Proficiency in Microsoft Excel and Word; ability to work with structured data and perform basic analysis (e.g., validation, comparisons, tracking updates).
- Experience supporting system testing (UAT, regression, or configuration validation).
- High attention to detail with a focus on data accuracy and configuration quality.
- Ability to troubleshoot system or workflow issues and communicate clearly with technical and non-technical stakeholders.
Preferred Qualifications
- Client facing experience preferred.
- Experience managing utilization management (UM) criteria preferred.
Benefits
- Medical and pharmacy coverage.
- Dental insurance.
- Vision insurance.
- Accidental injury insurance.
- Critical illness insurance.
- Hospital indemnity insurance.
- Flexible spending accounts.
- Health savings account.
- Voluntary life insurance.
- Voluntary accidental death and dismemberment insurance for themselves and their eligible dependents.
- Basic life insurance.
- Basic accidental death and dismemberment insurance.
- Paid time off.
- Sick time.
- Holidays.
- Short-term disability.
- Long-term disability.
- An employee assistance program.
- A wellness program.
- 401(k) plan with company match after one year of full-time employment.
About Judi Health
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:
- Capital Rx: A public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers.
- Judi Health™: Offering full-service health benefit management solutions to employers, TPAs, and health plans.
- Judi®: The industry’s leading proprietary Enterprise Health Platform (EHP), consolidating all claim administration-related workflows in one scalable, secure platform.
We are dedicated to rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve.
We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
New York, NY Salary Range: $128,000—$150,000 USD
Denver, CO Salary Range: $117,600—$147,000 USD
Charlotte, NC Salary Range: $106,800—$133,500 USD
All employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance.
This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health.
More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy.