Lead Appeals Pharmacist - Prior Authorization

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

Job summary

Judi Health seeks an experienced subject matter expert in prior authorization and appeals, ensuring compliance with federal and state standards across multiple lines of business. You will oversee PA processes, supervision of appeal pharmacists, and staff scheduling, with a focus on performance, training, and risk management.

You will perform PA and appeal reviews, discuss clinical decisions with providers, and collaborate with Medicare to align staffing and workflows.

Qualifications

• Doctor of Pharmacy (Pharm.D.) or Bachelor of Pharmacy from an accredited program.
• Active unrestrictive pharmacist license.
• 2 years as a clinical pharmacist in a PBM setting.
• 1+ year with Commercial and/or Medicare appeals.
• Strong PBM knowledge: claims processing, formulary, PA, and appeals.
• Analytical skills to review complex pharmacy claims and medical records.
• Leadership to motivate and manage a team; collaborative environment.
• Proficient with Word, Excel, PowerPoint, Outlook.

Responsibilities

• Supervise appeal pharmacists and technicians with expanded PA responsibilities.
• Oversee appeal job aids and clinical denial language.
• Analyze data with manager to optimize staffing, workflows and system enhancements.
• Train current staff and onboard new Appeals pharmacists.
• Investigate and resolve client/provider issues escalated.
• Collaborate with Medicare supervisor on staffing and workflows.
• Perform day-to-day clinical pharmacy functions including PA reviews and education calls.
• Make clinical decisions per medical necessity and contract criteria.
• Review literature to support provider decisions.

Skills

Pharmacist license

PBM experience

Clinical pharmacy

Leadership

Data analysis

Microsoft Office

Education

Pharm.D.

Bachelor of Pharmacy

Tools

Microsoft Office Suite

Job description

Judi Health seeks an experienced subject matter expert in prior authorization and appeals, ensuring compliance with federal and state standards across multiple lines of business. You will oversee PA processes, supervision of appeal pharmacists, and staff scheduling, with a focus on performance, training, and risk management.

You will perform PA and appeal reviews, discuss clinical decisions with providers, and collaborate with Medicare to align staffing and workflows.