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Prior Authorization Systems Pharmacist
Location
Colorado + 2 moreAll locations: Colorado | New York | North Carolina
Posted
1 day ago
Salary
$101.6K - $160K / year
Seniority
Senior
Job Description
Prior Authorization Systems Pharmacist
Capital Rx
• Responsible for the design, configuration, and quality assurance of prior authorization (PA) criteria • 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 • 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 to ensure alignment with clinical intent, 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 Commercial 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 develop reports • Respond to requests for clinical criteria from members and prescribers • Attend formulary meetings and presentations
Job 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 (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
- 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 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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