Prior Authorization Systems Pharmacist

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

Benefits offered by this job

Medical coverage

Dental insurance

Vision insurance

FSA/HSA

Job summary

Capital Rx is seeking a QA/QC focused professional to design, configure, and validate prior authorization criteria and decision trees. You will ensure clinical intent translates into compliant system logic through thorough QA/QC and validation processes.

In this role you will collaborate with internal teams and external clients to support delegated PA services, manage external vendors, and aid in system optimization.

Qualifications

• 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 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
• Collaborate with external clients for delegated clinical PA systems services
• Manage setup, contracting, and relationships with prior authorization external vendors
• Work with Director, Utilization Management on other responsibilities, projects, and initiatives as needed
• Identify PA reporting needs and collaborate with appropriate stakeholders to develop reports
• Attend formulary meetings and presentations as needed to stay abreast of all pertinent new information and changes

Skills

Health plan/PBM experience

Clinical presentation

Excel & Word

UAT / regression testing

Data analysis

Troubleshooting & communication

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
• Work 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 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
• Create and maintain commercial and government denial verbiage templates to remain up‑to‑date with criteria changes and 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

• 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

Preferred Qualifications

• Client facing experience preferred

Benefits

Full‑time employees are eligible for medical and pharmacy coverage, dental insurance, vision insurance, accidental injury insurance, critical illness insurance, hospital indemnity insurance, flexible spending accounts, health savings account, voluntary life insurance, voluntary accidental death and dismemberment insurance for themselves and eligible dependents. Additional benefits at no cost to the employee include basic life insurance, basic accidental death and dismemberment insurance, paid time off, sick time, holidays, short‑term disability, long‑term disability, employee assistance program, wellness program, and 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.