Position Summary:

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.

Position Responsibilities:

• 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

Minimum Qualifications:

• 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

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.

Nothing in this position description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

Benefits

Judi Health provides all full-time and part-time benefit-eligible employees with the ability to elect medical and pharmacy coverage, dental insurance, vision insurance, accidental injury insurance, critical illness insurance, hospital indemnity insurance, and flexible spending accounts. Full-time employees also have access to a health savings account, voluntary life insurance, and voluntary accidental death and dismemberment insurance for themselves and their eligible dependents.

Judi Health provides full-time employees with the following benefits at no cost to the employee: basic life insurance, basic accidental death and dismemberment insurance, paid time off, sick time, holidays, short-term disability, long-term disability, an employee assistance program, and a wellness program. Full-time employees are also eligible for a 401(k) plan with company match after one year of full-time employment.

New York, NY Salary Range

$128,000-$150,000 USD

Denver, CO Salary Range

$117,600-$147,000 USD

Charlotte, NC Salary Range

$106,800-$133,500 USD

All employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance. 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.