Capital Rx
Overview
Join to apply for the
Prior Authorization Systems Pharmacist
role at
Capital Rx .
1 day ago Be among the first 25 applicants
Join to apply for the
Prior Authorization Systems Pharmacist
role at
Capital Rx .
About Us Judi Health is a health technology company offering a wide range of benefits administration solutions for employers and health plans. This includes Capital Rx, a public benefit corporation that provides full-service pharmacy benefit management (PBM) solutions to self-insured employers; Judi Health, which offers comprehensive health benefit management solutions for employers, TPAs, and health plans; and Judi, the industry’s leading proprietary Enterprise Health Platform. To learn more, visit www.judi.health.
Position Summary We are seeking a licensed pharmacist to support the development and maintenance of clinical criteria and prior authorization system configurations. This role is responsible for writing utilization management policies, building decision trees, mapping letter templates, and creating template language for member-friendly communications. The ideal candidate will bring a detail-oriented mindset, excellent writing skills, and a deep understanding of prior authorization workflows to support efficient and accurate processes.
Position Responsibilities
Build decision trees and question sets from PA criteria for prior authorization review
Writing utilization management criteria policies based on clinical practice guidelines and plan benefit setup
Mapping of prior authorization notification letter templates in the prior authorization system
Batch-load testing within the prior authorization system of criteria and letter template configurations for accuracy
Review of criteria updates provided by the formulary operations team (weekly, quarterly, and ad hoc) for all lines of business
Weekly review and evaluation of the Medispan new drug to market report for changes that may cause disruption for members with current active prior authorizations
Responsible for updating PA criteria and associated product configurations in the prior authorization software within one week of receipt from formulary
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
Presents PA team members with significant changes to criteria or approval parameters, and responds to internal team member issues related to criteria questions and setup
Manages prior authorization self-service functions and configurations including, but not limited to, TAT configurations, denial verbiage templates, and fax back messaging to ensure compliance with state, federal, and other regulations
Works with the prior authorization software development team to identify and enhance the setup of criteria mapping and other self-service functions for review efficiency and compliance
Respond to requests for clinical criteria from members and prescribers
Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria.
Qualifications
Active, unrestricted, pharmacist license
Bachelor’s or Doctor of Pharmacy degree
2+ years of prior authorization review experience required
Experience managing clinical criteria strongly preferred
Formulary experience preferred
Strong communication, writing, and organizational skills Proficient in Microsoft Office Suite with emphasis on Microsoft Excel
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.
Salary Salary Range: $135,000—$145,000 USD
Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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Prior Authorization Systems Pharmacist
role at
Capital Rx .
1 day ago Be among the first 25 applicants
Join to apply for the
Prior Authorization Systems Pharmacist
role at
Capital Rx .
About Us Judi Health is a health technology company offering a wide range of benefits administration solutions for employers and health plans. This includes Capital Rx, a public benefit corporation that provides full-service pharmacy benefit management (PBM) solutions to self-insured employers; Judi Health, which offers comprehensive health benefit management solutions for employers, TPAs, and health plans; and Judi, the industry’s leading proprietary Enterprise Health Platform. To learn more, visit www.judi.health.
Position Summary We are seeking a licensed pharmacist to support the development and maintenance of clinical criteria and prior authorization system configurations. This role is responsible for writing utilization management policies, building decision trees, mapping letter templates, and creating template language for member-friendly communications. The ideal candidate will bring a detail-oriented mindset, excellent writing skills, and a deep understanding of prior authorization workflows to support efficient and accurate processes.
Position Responsibilities
Build decision trees and question sets from PA criteria for prior authorization review
Writing utilization management criteria policies based on clinical practice guidelines and plan benefit setup
Mapping of prior authorization notification letter templates in the prior authorization system
Batch-load testing within the prior authorization system of criteria and letter template configurations for accuracy
Review of criteria updates provided by the formulary operations team (weekly, quarterly, and ad hoc) for all lines of business
Weekly review and evaluation of the Medispan new drug to market report for changes that may cause disruption for members with current active prior authorizations
Responsible for updating PA criteria and associated product configurations in the prior authorization software within one week of receipt from formulary
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
Presents PA team members with significant changes to criteria or approval parameters, and responds to internal team member issues related to criteria questions and setup
Manages prior authorization self-service functions and configurations including, but not limited to, TAT configurations, denial verbiage templates, and fax back messaging to ensure compliance with state, federal, and other regulations
Works with the prior authorization software development team to identify and enhance the setup of criteria mapping and other self-service functions for review efficiency and compliance
Respond to requests for clinical criteria from members and prescribers
Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria.
Qualifications
Active, unrestricted, pharmacist license
Bachelor’s or Doctor of Pharmacy degree
2+ years of prior authorization review experience required
Experience managing clinical criteria strongly preferred
Formulary experience preferred
Strong communication, writing, and organizational skills Proficient in Microsoft Office Suite with emphasis on Microsoft Excel
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.
Salary Salary Range: $135,000—$145,000 USD
Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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