Prior Authorization Systems Pharmacist

<div class="content-intro"><h2><strong>About Judi Health</strong></h2> <p>Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels.<br><br>At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit <span><a href="http://www.judi.health" target="_blank">www.judi.health</a></span>.</p></div><p><strong><u>Position Summary:</u></strong></p> <p>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.</p> <p><strong><u>Position Responsibilities:</u></strong></p> <ul> <li>Build decision trees and question sets from PA criteria for prior authorization review</li> <li>Perform comprehensive quality control (QC) review of decision trees, questionnaires, and authorization logic to ensure alignment with clinical intent, regulatory requirements, and business rules</li> <li>Conduct quality assurance (QA) validation of configured criteria and decision paths, including scenario-based testing to confirm expected outcomes across approval and denial pathways</li> <li>Ensure PA questionnaires are configured with the appropriate authorization parameters for approval</li> <li>Collaborate with external clients for delegated clinical PA systems services</li> <li>Manage setup, contracting, and relationships with prior authorization external vendors</li> <li>Works with Director, Utilization Management on other responsibilities, projects, and initiatives as needed</li> <li>Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance</li> <li>Mapping of prior authorization member and prescriber letter templates