Prior Authorization Systems Pharmacist

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Capital 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, and
• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform.

Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health.

Responsible for the design, configuration, and quality assurance of prior authorization (PA) criteria, including decision trees, authorization parameters, and member/provider communications within the PA system. Ensures clinical intent is accurately translated into compliant, efficient system logic through structured QA/QC and validation processes. Collaborates with internal teams and external clients to support delegated PA services and drive system optimization.

• →Build decision trees and question sets from PA criteria for prior authorization review
• →Perform comprehensive quality control (QC) review of decision trees, questionnaires, and authorization logic to ensure alignment with clinical intent, regulatory requirements, and business rules
• →Conduct quality assurance (QA) validation of configured criteria and decision paths, including scenario-based testing to confirm expected outcomes across approval and denial pathways
• →Ensure PA questionnaires are configured with the appropriate authorization parameters for approval
• →Collaborate with external clients for delegated clinical PA systems services
• →Manage setup, contracting, and relationships with prior authorization external vendors
• →Works with Director, Utilization Management on other responsibilities, projects, and initiatives as needed
• →Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance
• →Mapping of prior authorization member and prescriber letter templates in the prior authorization system
• →Perform QC and QA review of member and prescriber letter templates to ensure accuracy, completeness, regulatory compliance, and alignment with configured decision logic
• →Validate that denial rationales, approval language, and conditional messaging accurately reflect clinical criteria and system outputs
• →Creation and maintenance of Commercial and Government denial verbiage templates to remain up to date with criteria changes and as needed to improve reviewer efficiency
• →Ensure denial rationale language is clinically sound, regulatory compliant, and consistently applied across all lines of business through structured QA review processes
• →Develops and maintains policies and procedures for creation and maintenance of clinical criteria questions and letter templates
• →Establish and maintain QA/QC standards, documentation, and audit processes for decision trees, criteria configurations, and letter templates
• →Identify PA reporting needs and collaborating with appropriate stakeholders to develop reports
• →Respond to requests for clinical criteria from members and prescribers
• →Attend formulary meetings and presentations as needed to stay abreast of all pertinent new information and changes
• →Collaborate with external clients for delegated clinical PA systems services
• →Manage setup, contracting, and relationships with prior authorization external vendors
• →Works with Director, Utilization Management on other responsibilities, projects, and initiatives as needed
• →Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

• Active, unrestricted, pharmacist license required
• 3+ years health plan or PBM pharmacy experience required
• Strong clinical background and presentation skills required
• Proficiency in Microsoft Excel and Word; ability to work with structured data and perform basic analysis (e.g., validation, comparisons, tracking updates)
• Experience supporting system testing (UAT, regression, or configuration validation) 
• 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

Preferred Qualifications:

• Client facing experience preferred
• Experience managing utilization management (UM) criteria preferred

• New York, NY (hybrid) $128,000 - $160,000
• Denver, CO (hybrid) $117,600 - $147,000  
• Charlotte, NC (hybrid) $106,800 - $133,500
• Remote - $101,600 - $160,000 (final salary within this range is determined by the candidate's geographic location and applicable market tier)

This range represents the low and high end of the anticipated base salary range. The actual base salary will depend on several factors such as: experience, knowledge, and skills, and location of the job.