Job Description:
• Responsible for the design, configuration, and quality assurance of prior authorization (PA) criteria
• 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
• Conduct QA validation of configured criteria and decision paths
• Manage setup, contracting, and relationships with prior authorization external vendors
• Ensure PA questionnaires are configured with appropriate authorization parameters for approval
• Collaborate with external clients for delegated clinical PA systems services
• Identify PA reporting needs and collaborate with appropriate stakeholders to develop reports
• Validate that denial rationales, approval language, and conditional messaging accurately reflect clinical criteria
• Develop and maintain policies and procedures for creation and maintenance of clinical criteria questions and letter templates
Requirements:
• Active, unrestricted, pharmacist license required
• 3+ years health plan or PBM pharmacy experience required
• Strong clinical background and presentation skills required
• Proficiency in Microsoft Excel and Word; ability to work with structured data and perform basic analysis
• 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
• Vision 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 at no cost
• Basic accidental death and dismemberment insurance at no cost
• 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