Prior Authorization Systems Pharmacist

Judi Health•Denver, CO

6d•$106,800 - $150,000

About The Position

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.

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

Nice To Haves

Client facing experience preferred
Experience managing utilization management (UM) criteria preferred

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
Works with Director, Utilization Management on other responsibilities, projects, and initiatives as needed
Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance
Mapping 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
Creation and maintenance of Commercial and Government denial verbiage templates to remain up to date with criteria changes and as needed to 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
Develops and maintains 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 collaborating with appropriate stakeholders to develop reports
Respond to requests for clinical criteria from members and prescribers
Attend formulary meetings and presentations as needed to stay abreast of all pertinent new information and changes