Prior Authorization Systems Pharmacist

Capital Rx

Prior Authorization Systems Pharmacist responsible for designing and ensuring quality assurance of prior authorization criteria. Collaborating with teams and clients at Judi Health to optimize medication access.

Posted 6/29/2026full-timeRemote • Colorado, New York, North Carolina • 🇺🇸 United StatesMid-LevelSenior💰 $101,600 - $160,000 per yearWebsite

About the role

Key responsibilities & impact

Responsible for the design, configuration, and quality assurance of prior authorization (PA) criteria
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
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
Mapping of prior authorization member and prescriber letter templates in the prior authorization system
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
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

Requirements

What you’ll need

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

Benefits

Comp & perks

medical and pharmacy coverage
dental insurance
vision insurance
accidental injury insurance
critical illness insurance
hospital indemnity insurance
flexible spending accounts
health savings account for full-time employees
voluntary life insurance
voluntary accidental death and dismemberment insurance for employees and eligible dependents
basic life insurance for full-time employees
basic accidental death and dismemberment insurance for full-time employees
paid time off
sick time
holidays
short-term disability
long-term disability
employee assistance program
wellness program
401(k) plan with company match after one year of full-time employment

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Decision Tree DevelopmentQuality Control ReviewSystem TestingData AnalysisConfiguration Validation

Soft Skills

Attention to DetailCommunication SkillsPresentation SkillsCollaboration

Certifications

Pharmacist License