Lead Appeals Pharmacist – Prior Authorization

Judi Health, LLC; New York (NY); On-site; USD 128,000 - 160,000; Full time

Job summary

Judi Health in New York, NY is seeking a subject matter expert on prior authorization and appeals operations compliant with federal, state, and other regulatory standards across Commercial, Medicare Part B&D, and Medicaid.

You will supervise appeal pharmacists and staff, develop workflow processes, provide ongoing training, and resolve escalated client issues while maintaining quality and productivity standards.

Qualifications

• Pharmacist degree (Pharm.D. or B.Pharm) from an accredited program.
• 2 years of clinical pharmacist experience in a PBM setting.
• 1+ year of Commercial and/or Medicare appeals experience.
• Strong PBM processes knowledge: claims, formulary, PA, appeals.
• Excellent analytical skills for complex claims review.
• Demonstrated leadership, team motivation, and collaboration.
• Proficiency with MS Office (Word, Excel, PowerPoint, Outlook).
• Ability to work EST hours Mon–Fri; on-call rotation for weekends/holidays.

Responsibilities

• Supervise a group of appeal pharmacists and technicians with expanded PA functions.
• Oversee appeal job aids and clinical denial language.
• Analyze data with the manager to recommend staffing and workflow improvements.
• Train current staff and onboard new Appeals pharmacists.
• Investigate and resolve escalated issues from clients and providers.
• Collaborate with the Medicare supervisor to align staffing and workflows.
• Perform day-to-day PA and appeal reviews and provide education calls to members/providers.
• Make clinical decisions per medical necessity and contract criteria.
• Use literature to support decisions and recommendations to providers.
• Communicate effectively with providers and members to promote positive health outcomes.
• Handle inbound inquiries regarding PA or appeals.
• Review pharmacy claims data for proactive outreach and quality interventions.
• Monitor trends to improve quality and cost effectiveness.
• Maintain quality and productivity standards and adhere to turnaround times.
• Participate in quality improvement activities per URAC.

Skills

Pharmacy degree or equivalent

PBM experience

Appeals experience

Data analysis

Leadership

MS Office proficiency

EST shift availability

Education

Pharmacist degree (Pharm.D. or B.Pharm)

Tools

Microsoft Word

Microsoft Excel

PowerPoint

Outlook

Job description

Judi Health in New York, NY is seeking a subject matter expert on prior authorization and appeals operations compliant with federal, state, and other regulatory standards across Commercial, Medicare Part B&D, and Medicaid.

You will supervise appeal pharmacists and staff, develop workflow processes, provide ongoing training, and resolve escalated client issues while maintaining quality and productivity standards.