Prior Authorization Systems Pharmacist & QA Architect

Judi Health, LLC; New York (NY); On-site; USD 128,000 - 150,000; Full time

Benefits offered by this job

Health benefits

Paid time off

401(k) with company match

Wellness program

Life insurance

Job summary

Judi Health, a health technology company, seeks a qualified professional to design, configure, and QA PA criteria within the prior authorization system. You will build decision trees, validate configurations, and ensure alignment with clinical intent and regulatory requirements while collaborating with internal teams and external clients.

The role requires 3+ years in health plan or PBM pharmacy, strong Excel/Word skills, and experience with UAT or configuration validation.

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

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 Judi Health 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
• Develops and maintains 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
• 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 Judi Health Code of Conduct including reporting of noncompliance

Skills

Clinical background

Presentation skills

Excel

Word

Data analysis

UAT testing

Job description

Judi Health, a health technology company, seeks a qualified professional to design, configure, and QA PA criteria within the prior authorization system. You will build decision trees, validate configurations, and ensure alignment with clinical intent and regulatory requirements while collaborating with internal teams and external clients.

The role requires 3+ years in health plan or PBM pharmacy, strong Excel/Word skills, and experience with UAT or configuration validation.