Prior Authorization Systems Specialist

Judi Health; New York (NY); Hybrid; USD 75,000 - 80,000; Full time

Job summary

Judi Health is seeking a PA Systems Specialist to maintain and validate prior authorization criteria, decision trees, and templates within the PA system. You will translate clinical requirements into system logic, collaborate with pharmacists and cross-functional teams, and ensure data integrity and compliant operations.

The role involves implementing formulary updates, configuring PA criteria, and supporting testing, validation, and communications to ensure timely and accurate authorizations

Qualifications

• 4+ years of pharmacy technician experience in a PBM, health plan, or clinical pharmacy environment.
• National Certified Pharmacy Technician (CPhT) certification required.
• Strong understanding of prior authorization workflows, clinical guidelines, and formulary management.
• Experience supporting system testing (UAT, regression, or configuration validation) preferred.
• Bachelor’s degree or equivalent combination of education and experience preferred.

Responsibilities

• Evaluate and operationalize weekly formulary and utilization management (UM) updates, including criteria changes, product additions, and retirements.
• Maintain and configure prior authorization (PA) criteria, rules, and source documentation within the PA platform, ensuring alignment with clinical and formulary intent.
• Experience creating or maintaining prior authorization decision trees, rules engines, or clinical workflows strongly preferred.
• Interpret clinical guidelines and translate them into structured logic or system configurations.
• Document clinical rationale or supporting materials for utilization management criteria.
• Perform structured validation and QA of criteria builds, letter templates, and system configurations prior to deployment.
• Partner with Formulary Operations and Clinical teams to identify and resolve discrepancies in criteria logic, coding, or documentation.
• Support new drug-to-market implementations, including analysis and updates for GPI, NDC, and other product identifiers.
• Maintain and enhance letter templates and automated communications to ensure regulatory compliance and operational consistency.
• Execute and support batch load testing, regression testing, and release validation for system updates and enhancements.
• Act as a subject matter resource for PA criteria setup, troubleshooting issues, and answering internal inquiries from operations, pharmacists, and business partners.
• Monitor and triage system or configuration issues, escalating appropriately and partnering with IT/vendor teams for resolution.
• Conduct intake and pre-review preparation of PA cases by validating member, provider, and clinical information against guideline requirements.
• Proactively obtain and organize clinical documentation to ensure completeness and readiness for pharmacist or clinician review.
• Collaborate cross-functionally with Clinical, Operations, IT, and Business teams to support system improvements, process optimization, and implementation initiatives.
• Identify opportunities for workflow efficiency, automation, and data quality improvement within the PA process.
• Adapt quickly to shifting priorities and support multiple concurrent initiatives in a fast-paced environment.

Skills

Attention to detail

Troubleshooting

Communication

Analytical thinking

Education

Bachelor’s degree or equivalent

Tools

Microsoft Excel

Microsoft Word

Job description

Judi Health is seeking a PA Systems Specialist to maintain and validate prior authorization criteria, decision trees, and templates within the PA system. You will translate clinical requirements into system logic, collaborate with pharmacists and cross-functional teams, and ensure data integrity and compliant operations.

The role involves implementing formulary updates, configuring PA criteria, and supporting testing, validation, and communications to ensure timely and accurate authorizations