Prior Authorization Systems Pharmacist
Posted on September 29, 2025 (about 3 hours ago)
About Us:
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 for employers, TPAs, and health plans; and Judi®, the industry’s leading proprietary Enterprise Health Platform. To learn more, visit www.judi.health.
Position Summary:
We are seeking a licensed pharmacist to support the development and maintenance of clinical criteria and prior authorization system configurations. Responsibilities include writing utilization management policies, building decision trees, mapping letter templates, and creating member-friendly communication templates. The role requires a detail-oriented mindset, excellent writing skills, and a deep understanding of prior authorization workflows to support efficient and accurate processes.
Position Responsibilities:
- Build decision trees and question sets from PA criteria for prior authorization review
- Write utilization management criteria policies based on clinical practice guidelines and plan benefit setup
- Map prior authorization notification letter templates in the prior authorization system
- Conduct batch-load testing within the prior authorization system of criteria and letter template configurations for accuracy
- Review criteria updates provided by the formulary operations team (weekly, quarterly, and ad hoc) for all lines of business
- Review and evaluate the Medispan new drug to market report weekly for changes affecting members with current active prior authorizations
- Update PA criteria and associated product configurations in the prior authorization software within one week of receipt from formulary
- Create and maintain Commercial and Government denial verbiage templates to stay current with criteria changes and improve reviewer efficiency
- Present significant changes to criteria or approval parameters to PA team members and respond to internal team member issues related to criteria questions and setup
- Manage prior authorization self-service functions and configurations including TAT configurations, denial verbiage templates, and fax back messaging to ensure regulatory compliance
- Collaborate with the prior authorization software development team to enhance criteria mapping and self-service functions for review efficiency and compliance
- Respond to requests for clinical criteria from members and prescribers
- Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria
Qualifications:
- Active, unrestricted pharmacist license
- Bachelor’s or Doctor of Pharmacy degree
- 2+ years of prior authorization review experience required
- Experience managing clinical criteria strongly preferred
- Formulary experience preferred
- Strong communication, writing, and organizational skills; proficient in Microsoft Office Suite with emphasis on Microsoft Excel
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.
Apply for this job
Please apply through the Capital Rx job board on Greenhouse where the original listing is posted. You can find the application form and submit your materials there.