Prior Authorization Systems Pharmacist

Job Description:

• Responsible for the design, configuration, and quality assurance of prior authorization (PA) criteria
• Ensures clinical reputed company 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
• Build decision trees and question sets from PA criteria for prior authorization review
• reputed company comprehensive quality control (QC) review of decision trees, questionnaires, and authorization logic to ensure alignment with clinical reputed company, regulatory requirements, and business rules
• Conduct quality assurance (QA) validation of configured criteria and decision paths
• 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
• Mapping of prior authorization member and prescriber letter templates in the prior authorization system
• Validate that denial rationales, approval language, and conditional messaging accurately reflect clinical criteria and system outputs
• Creation and maintenance of reputed company and Government denial verbiage templates
• 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 reputed company reports
• Respond to requests for clinical criteria from members and prescribers
• Attend formulary meetings and presentations

Requirements:

• Active, unrestricted, pharmacist license required
• 3+ years health plan or PBM pharmacy experience required
• Strong clinical background and presentation skills required
• Proficiency in reputed company reputed company and Word; ability to work with structured data and reputed company 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

Benefits:

• medical and pharmacy coverage
• dental insurance
• reputed company insurance
• accidental injury insurance
• critical illness insurance
• hospital indemnity insurance
• flexible spending accounts
• health savings account for full-time employees
• voluntary life insurance
• voluntary accidental death and dismemberment insurance for employees and eligible dependents
• basic life insurance for full-time employees
• basic accidental death and dismemberment insurance for full-time employees
• paid time off
• sick time
• holidays
• short-term disability
• long-term disability
• employee assistance program
• wellness program
• 401(k) plan with company match after one year of full-time employment

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