Prior Authorization Systems Technician

Benefits

Additional Information

About Judi Health Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including: Capital Rx , a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers, Judi Health™ , which offers full-service health benefit management solutions to employers, TPAs, and health plans, and Judi® , the industry's leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform. Together with our clients, we're rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health . Location: Remote (For Non-Local) or Hybrid (Local to New York, NY, Charlotte, NC or Denver, CO area) Position Summary Responsible for the maintenance, configuration, and validation of prior authorization (PA) criteria, decision trees, and communication templates within the PA system. Supports accurate translation of clinical requirements into system logic through routine updates, testing, and quality checks. Partners with pharmacists and cross-functional teams to ensure data integrity, resolve issues, and maintain efficient, compliant PA operations. Position Responsibilities: Evaluate and operationalize weekly formulary and utilization management (UM) updates, including criteria changes, product additions, and retirements Maintain and configure prior authorization (PA) criteria, rules, and source documentation within the PA platform, ensuring alignment with clinical and formulary intent Experience creating or maintaining prior authorization decision trees, rules engines, or clinical workflows strongly preferred Ability to interpret clinical guidelines and translate them into structured logic or system configurations Experience documenting clinical rationale or supporting materials for utilization management criteria preferred Perform structured validation and quality assurance (QA) of criteria builds, letter templates, and system configurations prior to deployment Partner with Formulary Operations and Clinical teams to identify and resolve discrepancies in criteria logic, coding, or documentation Support new drug-to-market implementations, including analysis and updates for GPI, NDC, and other product identifiers impacting existing authorizations Maintain and enhance letter templates and automated communications to ensure regulatory compliance and operational consistency Execute and support batch load testing, regression testing, and release validation for system updates and enhancements Act as a subject matter resource for PA criteria setup, troubleshooting issues, and answering internal inquiries from operations, pharmacists, and business partners Monitor and triage system or configuration issues, escalating appropriately and partnering with IT/vendor teams for resolution Conduct intake and pre-review preparation of PA cases by validating member, provider, and clinical information against guideline requirements Proactively obtain and organize clinical documentation to ensure completeness and readiness for pharmacist or clinician review Collaborate cross-functionally with Clinical, Operations, IT, and Business teams to support system improvements, process optimization, and implementation initiatives Identify opportunities for workflow efficiency, automation, and data quality improvement within the PA process Adapt quickly to shifting priorities and support multiple concurrent initiatives in a fast-paced environment Required Qualifications: 4+ years of pharmacy technician experience in a PBM, health plan, or clinical pharmacy environment Demonstrated experience working with prior authorization systems, UM criteria, or clinical rule configuration National Certified Pharmacy Technician (CPhT) certification required Strong understanding of prior authorization workflows, clinical guidelines, and formulary management Experience supporting system testing (UAT, regression, or configuration validation) preferred 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 Proficiency in Microsoft Excel and Word; ability to work with structured data and perform basic analysis (e.g., validation, comparisons, tracking updates) Experience working cross-functionally with clinical, operational, and/or IT teams preferred Bachelor's degree or equivalent combination of education and experience preferred Base Salary: New York, NY (hybrid) $75,000 - $80,000 Denver, CO (hybrid) $75,000 - $80,000 Charlotte, NC (hybrid) $75,000 - $80,000 Remote - $75,000 - $80,000 (final salary within this range is determined by the candidate's geographic location and applicable market tier) This range represe

Your Match

How well this role fits your profile.

Company Intel

What employees say

Worked at capitalrx? Share your experience