Prior Authorization Systems Pharmacist

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🕒 Yesterday

⛰️ Colorado, New York, +1 more states – Remote

⛰️ Colorado – Remote 🗽 New York – Remote 🌲 North Carolina – Remote

💵 $101.6k - $160k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

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Capital Rx

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2017

⚕️ Healthcare Insurance

💳 Fintech

🤖 Artificial Intelligence

Healthcare Insurance • Fintech • Artificial Intelligence

Capital Rx is the fastest growing healthtech company in America, dedicated to transforming the prescription pricing and patient care landscape. Founded in 2017, it offers innovative pharmacy benefit management (PBM) services, including customizable pharmacy benefits for large employers and an AI-powered care navigation platform. Capital Rx focuses on delivering cost-effective solutions and operational efficiencies to clients while ensuring transparency and quality care for patients.

📋 Description

• 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

🎯 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