Prior Authorization Systems Pharmacist - Design & QA

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

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