Prior Authorization Systems Pharmacist

About Judi Health

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.

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