Judi Health is a health technology company offering a wide range of benefits administration solutions for employers and health plans, including Capital Rx, a public benefit corporation providing full-service pharmacy benefit management (PBM) solutions to self-insured employers, Judi Health™ offering comprehensive health benefit management solutions, and Judi®, the industry's leading proprietary Enterprise Health Platform.

The Lead Clinical Care Prior Authorization Pharmacist will oversee and manage the daily clinical pharmacy functions related to prior authorization reviews, override requests, member/provider education, and phone support. They ensure efficient processing of medication requests while adhering to medical necessity and contractual criteria. This role also supports Clinical care pharmacists, providing guidance and ensuring high-quality performance aligned with company goals, regulatory standards, and client requirements.

Perform and oversee day-to-day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.

Support the training and development of staff to enhance their skills and knowledge.

Contribute to quality improvement initiatives and clinical operations projects.

Collaborate with business and clinical partners to improve workflows and ensure process consistency.

Promote a collaborative team environment and provide guidance on best clinical pharmacy practices.

Lead projects to improve pharmacy operations, member care, and clinical outcomes.

Work scheduled shift 2:00pm-11:00pm EST with rotating weekends.

Serve as a subject matter expert on clinical medication reviews, providing consultation to pharmacy team, healthcare providers, and stakeholders.

Monitor and manage queues ensuring regulatory and internal compliance.

Collaborate with compliance, quality assurance, and pharmacy teams to identify risk mitigation strategies and ensure accurate clinical review processing.

Make clinical decisions according to medical necessity and contract criteria.

Perform scientific literature evaluation to support decision-making and provider recommendations.

Communicate effectively with providers and members to promote positive health outcomes.

Provide backup call center support as needed.

Review pharmacy claims data for proactive outreach and intervention.

Identify and monitor inappropriate trends to improve quality and cost effectiveness.

Maintain quality and productivity standards while meeting turnaround time requirements.

Work with business and clinical partners as needed in a fast-paced environment with shifting priorities.

Adhere to Capital Rx Code of Conduct including reporting noncompliance.

Active, unrestricted pharmacist license.

Bachelor's or Doctor of Pharmacy Degree with 2+ years of pharmacy practice experience.

Experience in customer service, call center, and prior authorization.

Excellent communication, writing, and organizational skills.

Ability to work independently with minimal supervision in a remote, high-volume, metric-driven call center environment.

Self-motivated and detail-oriented problem solver.

Ability to handle multiple competing priorities in a dynamic environment and collaborate in a team.

Designated workspace that is visibly secure and protected from noise during work hours (closed door).

Internet connectivity via DSL, cable modem or fiber with wired connection to device (no Wi-Fi); internet speed of 1 gigabyte required.

Working knowledge of MS Office.

$130,000 - $140,000 USD