Supervisor, Appeals Pharmacist

Capital Rx; Denver (CO); On-site; USD 118,000 - 147,000; Full time

Job summary

Judi Health seeks a subject matter expert in prior authorization and appeals to ensure regulatory compliance across Commercial, Medicare, and Medicaid lines. You will oversee PA workflows, mentor staff, and manage clinical denial language while collaborating with managers to optimize staffing and performance.

Responsibilities include direct PA reviews, education calls, data analysis, and coordinating with Medicare and providers to ensure appropriate decisions and timely processing.

Qualifications

• Pharm.D. or Bachelor of Pharmacy from an accredited program.
• Active pharmacist license.
• 2 years of experience as a clinical pharmacist in a PBM setting.
• 1+ year of experience with Commercial and/or Medicare appeals.
• Strong PBM processes knowledge: claims, formulary, PA and appeals.
• Excellent analytical skills for complex claims and records.
• Strong leadership and team management abilities.
• Proficiency with Microsoft Office Suite.
• Ability to work EST hours Mon-Fri; on-call rotation weekends/holidays.

Responsibilities

• Supervise a group of appeal pharmacists and technicians.
• Oversee appeal job aids and clinical denial language.
• Analyze data with the manager and recommend staffing/workflow changes.
• Train current staff and onboard new Appeals pharmacists.
• Investigate/resolve escalated issues from clients and providers.
• Collaborate on projects, initiatives, and process improvements.
• Work with Medicare supervisor on staffing and workflows.
• Perform day-to-day PA and appeal reviews and education calls.
• Make clinical decisions per medical necessity and contract criteria.
• Evaluate literature to support provider recommendations.
• Communicate with providers and members to promote outcomes.
• Handle inbound inquiries regarding PA/appeals.
• Review claims data for outreach and intervention.
• Identify trends to improve care quality and cost.

Skills

Leadership

Analytical skills

PBM knowledge

Provider communication

Workflow optimization

Education

Doctor of Pharmacy (Pharm.D.) or Bachelor of Pharmacy

Tools

Microsoft Office Suite

Job description

About Judi Health

Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels. At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health.

Position Summary

Acts as subject matter expert on prior authorization and appeals operations that are compliant to federal, state, and other regulatory standards for multiple lines of business including Commercial, Commercial Exchange, FEHB, Medicare Part B&D, and Medicaid, and responsible for the oversight of prior authorization processes of prior authorization pharmacists, staff schedules, skilling, performance and managing compliance risks.

Position Responsibilities

• Responsible for supervision of a group of appeal pharmacists and technicians with expanded responsibility for select administrative PA functions.
• Oversight of appeal job aids and clinical denial language.
• Work in conjunction with Manager in analyzing available data and provide prior authorization staffing, workflow and system enhancement recommendations.
• Support on-going training of current staff and onboarding new Appeals pharmacists.
• Investigate/resolve escalated issues or problems from clients and providers.
• Works with appeal manager on other responsibilities, projects, implementations and initiatives as needed.
• Collaborate with Medicare supervisor to ensure appropriate staffing and develop workflow processes.
• Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
• Make clinical decisions in accordance with medical necessity and contract criteria
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers
• Communicate effectively with providers and members to promote positive health outcomes
• Handle inbound phone inquiries regarding prior authorization and or appeal requests.
• Review pharmacy claims data for proactive outreach and intervention
• Identify and monitor inappropriate trends in care to improve quality and cost effectiveness
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements
• Participates in the quality improvement committee and supports quality improvement projects as required by URAC (5-10% of time)
• Work with business and clinical partners as needed
• Ability to work in a fast-paced environment with shifting priorities
• Prior authorization queue management, supervise the daily operation of the queue, monitor for compliance risk and update skilling based on business needs

Minimum Qualifications

• A Doctor of Pharmacy (Pharm.D.) degree or Bachelor of Pharmacy degree from an accredited pharmacy program.
• An active unrestrictive pharmacist license.
• 2 years of experience as a clinical pharmacist in a Pharmacy Benefit Management (PBM) setting.
• 1+ year of experience working with Commercial and/or Medicare appeals.
• Strong understanding of pharmacy benefit management processes, including claims processing, formulary management, prior authorization, and appeals.
• Excellent analytical skills, showcasing an ability to analyze complex pharmacy claims and medical records, identify issues, and propose appropriate solutions.
• Strong leadership skills, including the ability to motivate and manage a team, provide guidance, and support, and foster a collaborative work environment.
• Proficiency in using Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
• Ability to work any shift EST Monday through Friday as well as on-call rotation for weekends, holidays, and after-hours.

Preferred Qualifications

• 1+ year of leadership experience in a remote environment.

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: $128,000 — $160,000 USD

Denver, CO Salary Range: $117,600 — $147,000 USD

Charlotte, NC Salary Range: $106,800 — $133,500 USD

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.

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.

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 athttps://www.judi.health/legal/privacy-policy.