Prior Authorization Systems Technician

Position Summary

Responsible for the maintenance, configuration, and validation of prior authorization (PA) criteria, decision trees, and communication templates within the PA system. Supports accurate translation of clinical requirements into system logic through routine updates, testing, and quality checks. Partners with pharmacists and cross-functional teams to ensure data integrity, resolve issues, and maintain efficient, compliant PA operations.

Position Responsibilities

• Evaluate and operationalize weekly formulary and utilization management (UM) updates, including criteria changes, product additions, and retirements
• Maintain and configure prior authorization (PA) criteria, rules, and source documentation within the PA platform, ensuring alignment with clinical and formulary intent
• Experience creating or maintaining prior authorization decision trees, rules engines, or clinical workflows strongly preferred
• Ability to interpret clinical guidelines and translate them into structured logic or system configurations
• Experience documenting clinical rationale or supporting materials for utilization management criteria preferred
• Perform structured validation and quality assurance (QA) of criteria builds, letter templates, and system configurations prior to deployment
• Partner with Formulary Operations and Clinical teams to identify and resolve discrepancies in criteria logic, coding, or documentation
• Support new drug-to-market implementations, including analysis and updates for GPI, NDC, and other product identifiers impacting existing authorizations
• Maintain and enhance letter templates and automated communications to ensure regulatory compliance and operational consistency
• Execute and support batch load testing, regression testing, and release validation for system updates and enhancements
• Act as a subject matter resource for PA criteria setup, troubleshooting issues, and answering internal inquiries from operations, pharmacists, and business partners
• Monitor and triage system or configuration issues, escalating appropriately and partnering with IT/vendor teams for resolution
• Conduct intake and pre-review preparation of PA cases by validating member, provider, and clinical information against guideline requirements
• Proactively obtain and organize clinical documentation to ensure completeness and readiness for pharmacist or clinician review
• Collaborate cross-functionally with Clinical, Operations, IT, and Business teams to support system improvements, process optimization, and implementation initiatives
• Identify opportunities for workflow efficiency, automation, and data quality improvement within the PA process
• Adapt quickly to shifting priorities and support multiple concurrent initiatives in a fast-paced environment