Prior Authorization Systems Pharmacist

Judi Health; Denver (CO); On-site; USD 117,600 - 147,000; Full time

Benefits offered by this job

Medical and pharmacy coverage

Dental insurance

Vision insurance

Life insurance

Short-term disability

Long-term disability

Employee assistance program

Wellness program

401(k) with company match after 1 year

Health savings account

Job summary

Judi Health seeks an experienced pharmacist to design, configure, and QA PA criteria and decision trees within the PA system. You will translate clinical intent into compliant system logic and validate outcomes through structured QC/QC processes, working with internal teams and external clients to support delegated PA services.

You will also manage vendor relationships, ensure accurate denial/approval messaging, and develop templates to stay compliant with changing criteria.

Qualifications

• Active, unrestricted pharmacist license is required.
• 3+ years health plan or PBM pharmacy experience.
• Strong clinical background and presentation skills.
• Proficiency with Microsoft Excel and Word for data analysis.
• Experience supporting system testing (UAT, regression, or configuration validation).
• High attention to detail with data accuracy and configuration quality.
• Ability to troubleshoot system/workflow issues and communicate with technical and non-technical stakeholders.

Responsibilities

• Build decision trees and question sets from PA criteria for prior authorization review.
• Perform QC review of decision trees, questionnaires, and authorization logic for alignment with clinical intent and regulatory requirements.
• Conduct QA validation of configured criteria and decision paths with scenario-based testing.
• Ensure PA questionnaires have appropriate authorization parameters for approval.
• Collaborate with external clients for delegated PA system services.
• Manage setup, contracting, and relationships with external PA vendors.
• Maintain QA/QC standards, documentation, and audit processes for criteria and templates.
• Identify PA reporting needs and develop reports.
• Respond to requests for clinical criteria from members and prescribers.

Skills

Pharmacist license

Health plan / PBM experience

Clinical presentation skills

Microsoft Excel

Microsoft Word

System testing experience

Attention to detail

Troubleshooting

Education

Active pharmacist license (Pharmacist license)

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
• Mapping of 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
• 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 collaborating 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 (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
• Experience managing utilization management (UM) criteria preferred
• Depending on the changing needs of the business, you may be required to work rotating weekends and/or participate in an on-call schedule in the future.

Benefits

Judi Health provides all full-time and part-time benefit-eligible employees with the ability to 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 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. Full-time employees are also eligible for a 401(k) plan with company match after one year of full-time employment.

Salary Ranges

New York, NY: $128,000 USD - $150,000 USD

Denver, CO: $117,600 USD - $147,000 USD

Charlotte, NC: $106,800 USD - $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.

Privacy Notice

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.