Prior Authorization Systems Pharmacist

Capitalrx; Charlotte (NC); On-site; USD 106,800 - 133,500; Full time

Job summary

CapitalRx is seeking a licensed pharmacist to design, configure, and QA prior authorization criteria, decision trees, and member/provider communications within the PA system. You will translate clinical intent into compliant, efficient system logic through structured QA/QC and validation, and collaborate with internal teams and external clients to support delegated PA services.

Responsibilities include building decision trees, performing QC/QA validation, mapping denial/approval templates, and

Qualifications

• Active pharmacist license
• 3+ years health plan or PBM pharmacy experience
• Strong clinical background and presentation skills
• Proficiency in Microsoft Excel and Word; ability to work with structured data and perform basic analysis
• 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

Responsibilities

• Build decision trees and questionnaires for PA review
• Perform QC/QA validation of criteria and decision paths
• Map PA member and prescriber letter templates
• Validate denial/approval language and messaging
• Manage setup, contracting, and relationships with external vendors
• Collaborate with external clients for delegated PA systems services
• Adhere to Capital Rx Code of Conduct and report noncompliance
• Establish QA/QC standards and audit processes for decision trees and templates
• Identify PA reporting needs and respond to criteria requests

Skills

Pharmacist license

PBM experience

Clinical presentation

Excel

Word

System testing

Attention to detail

Stakeholder communication

Education

PharmD

Tools

Microsoft Excel

Microsoft Word

Job description

Position Summary

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.

Position 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
• Map prior authorization member and prescriber letter templates in the PA 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
• 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 as needed to stay abreast of all pertinent new information and changes

Minimum Qualifications

• 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
• 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

Benefits

Full‑time and part‑time benefit‑eligible employees may elect medical and pharmacy coverage, dental insurance, vision insurance, accidental injury insurance, critical illness insurance, hospital indemnity insurance, and flexible spending accounts. Full‑time employees also have access to a health savings account, voluntary life insurance, and voluntary accidental death and dismemberment insurance for themselves and their eligible dependents.

Full‑time employees also receive 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, and a wellness program at no cost to the employee. Full‑time employees are eligible for a 401(k) plan with company match after one year of full‑time employment.

Salary Range

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

Equal Employment Opportunity Statement

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Code of Conduct and Privacy

All employees are responsible for adherence to the Judi Health Code of Conduct, including the reporting of non‑compliance.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health’s privacy practices can be found at https://www.judi.health/legal/privacy-policy.