Prior Authorization Systems Pharmacist
New
J
Judi HealthPharmacy Benefit Management
RemoteFull-TimeMiddle
Salary101,600 - 160,000 USD per year
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Job Details
- Experience
- 3+ years
- Required Skills
- Data AnalysisMicrosoft ExcelQuality Assurance
Requirements
- 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 such as validation, comparisons, and 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.
- Ability to communicate clearly with technical and non-technical stakeholders.
- Client facing experience preferred.
- Experience managing utilization management (UM) criteria preferred.
Responsibilities
- Build decision trees and question sets from PA criteria for prior authorization review.
- Perform comprehensive quality control review of decision trees, questionnaires, and authorization logic.
- Conduct quality assurance validation of configured criteria and decision paths, including scenario-based testing.
- Map prior authorization member and prescriber letter templates in the system.
- Manage setup, contracting, and relationships with prior authorization external vendors.
- Create and maintain Commercial and Government denial verbiage templates.
- Develop and maintain policies and procedures for clinical criteria questions and letter templates.
- Establish QA/QC standards, documentation, and audit processes for system configurations.
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