Prior Authorization Systems Pharmacist – Criteria Design & QA

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

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.