Prior Authorization Quality Assurance Pharmacist
Posted on October 29, 2025 (about 4 hours ago)
About Us:
Judi Health is a health technology company offering a wide range of benefits administration solutions for employers and health plans. This includes Capital Rx, providing full-service pharmacy benefit management (PBM) solutions to self-insured employers, Judi Health™, which offers comprehensive health benefit management solutions, and Judi®, the industry-leading proprietary Enterprise Health Platform.
Position Summary:
The QA Pharmacist conducts routine audits and monitoring to ensure quality, accuracy, and compliance of coverage requests and appeals. Utilizes knowledge of regulatory requirements for reporting and audits.
Position Responsibilities:
- Complete monthly utilization management and appeals performance and process audits per regulations, accreditation standards, and best practices.
- Create and maintain progress reports and audit results aligned with regulatory/accreditation requirements and internal processes.
- Present audit results to leadership to address compliance issues promptly.
- Stay informed on regulatory/accreditation updates affecting coverage request and appeals.
- Respond to inquiries on quality assurance, audit results, and compliance policies.
- Work independently and collaboratively on audit assignments.
- Assist in designing audit tools, QA scorecards, and guides with stakeholders.
- Provide ongoing performance feedback to team leads.
- Help management identify and mitigate operational and compliance risks.
- Collaborate with operational leaders to identify training needs and improve policies and procedures.
Minimum Qualifications:
- Active, unrestricted pharmacist license required.
- 2+ years utilization management experience required.
- Extensive knowledge operationalizing regulatory requirements.
- Strong oral and written communication skills.
- Intermediate to advanced Microsoft Excel skills.
- Strong analytical skills, attention to detail, quantitative and problem-solving abilities.
- Ability to work independently, remotely, in a high-volume, metrics-driven environment.
- Ability to multitask and collaborate under shifting priorities.
Preferred Qualifications:
- Familiarity/experience with URAC and NCQA accreditation.
- Utilization management and/or appeals audit experience.
- 1+ years compliance or regulatory experience at PBM or health plan.
This position description is flexible to meet organizational goals as assigned by management.
Apply via the provided application form on the job post page including uploading resume/CV and cover letter if desired.
Application Requirements:
- Complete required fields in the online form.
- Attach a resume/CV in an accepted file format (pdf, doc, docx, txt, rtf).
- Optionally attach a cover letter.
Submission is through the Greenhouse platform interface.