Prior Authorization Systems Technician

Judi Health; Charlotte (NC); Hybrid; USD 75,000 - 80,000; Full time

Job summary

Judi Health is seeking a PA Operations Specialist to maintain and validate prior authorization criteria, decision trees, and templates. You will translate clinical requirements into system logic, test configurations, and partner with pharmacists and cross‑functional teams to ensure compliant PA operations.

You will support weekly formulary updates, authorizations, and templates, while ensuring data integrity and regulatory compliance across multiple product identifiers and updates.

Qualifications

• 4+ years of pharmacy technician experience in a PBM, health plan, or clinical pharmacy environment.
• Demonstrated experience working with prior authorization systems, UM criteria, or clinical rule configuration.
• Strong understanding of prior authorization workflows, clinical guidelines, and formulary management.
• Experience supporting system testing (UAT, regression, or configuration validation) preferred.
• 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.
• Proficiency in Microsoft Excel and Word; ability to work with structured data and perform basic analysis.
• Experience working cross‑functionally with clinical, operational, and/or IT teams 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 preferred.
• Perform structured validation and quality assurance (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 impacting existing authorizations.
• 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

Pharmacy technician

PA systems

UM criteria

Clinical guidelines

Data analysis

Excel/Word

Cross-functional collaboration

Education

Bachelor’s degree or equivalent

Job description

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Judi Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers,
• Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and
• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform.

Location: Hybrid (Local to New York, NY, Charlotte, NC or Denver, CO area)

Position Summary

Responsible for the maintenance, configuration, and validation of prior authorization (PA) criteria, decision trees, and communication templates within the PA system. Supports accurate translation of clinical requirements into system logic through routine updates, testing, and quality checks. Partners with pharmacists and cross‑functional teams to ensure data integrity, resolve issues, and maintain efficient, compliant PA operations.

Position 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 preferred
• Perform structured validation and quality assurance (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 impacting existing authorizations
• 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

Required Qualifications

• 4+ years of pharmacy technician experience in a PBM, health plan, or clinical pharmacy environment
• Demonstrated experience working with prior authorization systems, UM criteria, or clinical rule configuration
• Strong understanding of prior authorization workflows, clinical guidelines, and formulary management
• Experience supporting system testing (UAT, regression, or configuration validation) preferred
• 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
• Proficiency in Microsoft Excel and Word; ability to work with structured data and perform basic analysis (e.g., validation, comparisons, tracking updates)
• Experience working cross‑functionally with clinical, operational, and/or IT teams preferred
• Bachelor’s degree or equivalent combination of education and experience preferred

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

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.

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.

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non‑compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

New York, NY Salary Range: $75,000 - $80,000 USD

Denver, CO Salary Range: $75,000 - $80,000 USD

Charlotte, NC Salary Range: $75,000 - $80,000 USD