Lead Appeals Pharmacist - Prior Authorization Expert

Capital Rx; Denver (CO); On-site; USD 118,000 - 147,000; Full time

Job summary

Judi Health seeks a subject matter expert in prior authorization and appeals to ensure regulatory compliance across Commercial, Medicare, and Medicaid lines. You will oversee PA workflows, mentor staff, and manage clinical denial language while collaborating with managers to optimize staffing and performance.

Responsibilities include direct PA reviews, education calls, data analysis, and coordinating with Medicare and providers to ensure appropriate decisions and timely processing.

Qualifications

• Pharm.D. or Bachelor of Pharmacy from an accredited program.
• Active pharmacist license.
• 2 years of experience as a clinical pharmacist in a PBM setting.
• 1+ year of experience with Commercial and/or Medicare appeals.
• Strong PBM processes knowledge: claims, formulary, PA and appeals.
• Excellent analytical skills for complex claims and records.
• Strong leadership and team management abilities.
• Proficiency with Microsoft Office Suite.
• Ability to work EST hours Mon-Fri; on-call rotation weekends/holidays.

Responsibilities

• Supervise a group of appeal pharmacists and technicians.
• Oversee appeal job aids and clinical denial language.
• Analyze data with the manager and recommend staffing/workflow changes.
• Train current staff and onboard new Appeals pharmacists.
• Investigate/resolve escalated issues from clients and providers.
• Collaborate on projects, initiatives, and process improvements.
• Work with Medicare supervisor on staffing and workflows.
• Perform day-to-day PA and appeal reviews and education calls.
• Make clinical decisions per medical necessity and contract criteria.
• Evaluate literature to support provider recommendations.
• Communicate with providers and members to promote outcomes.
• Handle inbound inquiries regarding PA/appeals.
• Review claims data for outreach and intervention.
• Identify trends to improve care quality and cost.

Skills

Leadership

Analytical skills

PBM knowledge

Provider communication

Workflow optimization

Education

Doctor of Pharmacy (Pharm.D.) or Bachelor of Pharmacy

Tools

Microsoft Office Suite

Job description

Judi Health seeks a subject matter expert in prior authorization and appeals to ensure regulatory compliance across Commercial, Medicare, and Medicaid lines. You will oversee PA workflows, mentor staff, and manage clinical denial language while collaborating with managers to optimize staffing and performance.

Responsibilities include direct PA reviews, education calls, data analysis, and coordinating with Medicare and providers to ensure appropriate decisions and timely processing.