Prior Authorization Systems Pharmacist

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including Judi Rx (a public benefit corporation delivering full-service pharmacy benefit management solutions to self-insured employers), Judi Health™ (full-service health benefit management solutions for employers, TPAs, and health plans), and Judi® (the industry’s leading proprietary Enterprise Health Platform consolidating all claim administration-related workflows in one scalable, secure platform). Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure needed for the care we deserve. Learn more.

About the role

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. Ensures clinical intent is accurately translated into compliant, efficient system logic through structured QA/QC and validation processes. Collaborates with internal teams and external clients to support delegated PA services and drive system optimization.

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
• Map 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
• Create and maintain Commercial and Government denial verbiage templates to remain up to date with criteria changes and improve reviewer efficiency
• Ensure denial rationale language is clinically sound, regulatory compliant, and consistently applied across all lines of business through structured QA review processes
• 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
• Respond to requests for clinical criteria from members and prescribers
• Attend formulary meetings and presentations to stay abreast of pertinent new information and changes
• 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

Requirements

• 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

Depending on the changing needs of the business, you may be required to work rotating weekends and/or participate in an on-call schedule in the future.

Benefits

Judi Health provides all full-time and part-time benefit-eligible employees with the ability to elect:

• Medical and pharmacy coverage
• Dental insurance
• Vision insurance
• Accidental injury insurance
• Critical illness insurance
• Hospital indemnity insurance
• Flexible spending accounts

Full-time employees also have access to:

• A health savings account
• Voluntary life insurance
• Voluntary accidental death and dismemberment insurance for themselves and their eligible dependents

Judi Health provides full-time employees with the following benefits at no cost:

• 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

Full-time employees are also eligible for a 401(k) plan with company match after one year of full-time employment.

Pay

• New York, NY: $128,000 – $150,000 USD
• Denver, CO: $117,600 – $147,000 USD
• Charlotte, NC: $106,800 – $133,500 USD