Prior Authorization Systems Technician

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

Job summary

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

You will lead QA of criteria builds, support new drug-to-market updates, and ensure precise letter templates and automated communications for regulatory compliance.

Qualifications

• 4+ years of pharmacy technician experience in a PBM, health plan, or clinical pharmacy environment.
• 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 PA criteria, rules, and source documentation within the PA platform, ensuring alignment with clinical and formulary intent.
• Experience creating or maintaining PA 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 UM criteria where applicable.
• Perform structured validation and quality assurance (QA) of criteria builds, letter templates, and system configurations before deployment.
• Partner with Formulary Operations and Clinical teams to identify and resolve discrepancies in criteria logic, coding, or documentation.

Skills

Attention to detail

Cross-functional collaboration

Troubleshooting

Education

National Certified Pharmacy Technician (CPhT) certification

Bachelor’s degree or equivalent

Tools

Microsoft Excel

Microsoft Word

Job description

About Judi Health

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.
• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), consolidating all claim administration‑related workflows in a 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 PA criteria, rules, and source documentation within the PA platform, ensuring alignment with clinical and formulary intent.
• Experience creating or maintaining PA 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 UM criteria where applicable.
• Perform structured validation and quality assurance (QA) of criteria builds, letter templates, and system configurations before 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.
• Serve 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.
• 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.
• 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.
• 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.

Benefits

Full‑time and part‑time benefit‑eligible employees may elect medical and pharmacy coverage, dental insurance, vision insurance, accidental injury insurance, critical illness insurance, hospital indemnity insurance, and flexible spending accounts. Full‑time employees also have access to a health savings account, voluntary life insurance, and voluntary accidental death and dismemberment insurance for themselves and eligible dependents.

Full‑time employees receive basic life insurance, basic accidental death and dismemberment insurance, paid time off, sick time, holidays, short‑term disability, long‑term disability, an employee assistance program, and a wellness program at no cost. Full‑time employees are also eligible for a 401(k) plan with company match after one year of full‑time employment.

Equal Employment Opportunity

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.

Salary Range

New York, NY: $75,000 – $80,000 USD

Denver, CO: $75,000 – $80,000 USD

Charlotte, NC: $75,000 – $80,000 USD

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.