Prior Authorization Clinical Criteria – Policy Coordinator

🔥 45 minutes ago

☕ Washington – Remote

☕ Washington – Remote

💵 $25 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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TrueScripts Management Services

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2014

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

TrueScripts Management Services is dedicated to providing exceptional prescription benefit management services. With a focus on delivering maximum savings and amazing care, TrueScripts works closely with members, clients, brokers, and prescribers to offer personalized and customized solutions. The company prides itself on transparency and efficiency, featuring a 24-48 hour turnaround time for prior authorization requests and a commitment to customer service, ensuring that real people are available to assist over 99% of the time.

📋 Description

• Draft clinical criteria policies and question sets for medications requiring prior authorization using FDA labeling, clinical guidelines, and drug compendia • Perform initial quality checks for clinical accuracy and guideline alignment • Identify medications needing new or updated criteria using dashboards and reporting • Submit criteria for pharmacist and policy committee review and approval • Prepare summary materials and supporting documentation for policy committee review • Maintain the master criteria tracking log in Confluence, including approvals, effective dates, review dates, and version history • Build approved criteria and question sets in the prior authorization platform • Develop and execute test cases for question logic, branching, and outcomes • Migrate approved and tested policies to production and maintain version control • Build and maintain prior authorization forms and correspondence templates • Research and incorporate state-specific prior authorization requirements under Compliance guidance • Maintain reference logs of state-specific requirements by state and client/plan • Implement compliant member notifications for approvals, denials, and appeal rights • Steward the Confluence criteria repository and archive retired or superseded criteria • Create and update job aids for the Prior Authorization Coordinator Team • Communicate criteria updates and workflow changes to internal teams and stakeholders • Serve as a subject matter resource on criteria application • Support client, URAC/NCQA, and state regulatory audits • Audit criteria effective dates and alignment with plan parameters • Assist with appeals or grievance reviews by providing criteria documentation and rationale • Manage expedited criteria development for urgent situations • Perform other duties as assigned

🎯 Requirements

• High school diploma required; two-year degree preferred • Pharmacy technician experience strongly preferred • Experience with pharmacy prior authorizations, PBM operations, or clinical criteria drafting strongly preferred • Strong research skills, including the ability to interpret FDA labeling, clinical guidelines, and drug literature • Excellent written communication skills for policy drafting, documentation, and cross-team communication • Experience with a prior authorization platform or similar processing/workflow software preferred • Familiarity with Confluence or similar knowledge management tools • Strong organizational skills and attention to detail; ability to manage multiple criteria projects simultaneously • Proficiency in Microsoft Office 365 (Word, Excel, Outlook, etc.) • Ability to work independently while collaborating closely with pharmacists, the policy committee, and the Prior Authorization Coordinator Team • Proactive, detail-oriented mindset with strong problem-solving and analytical thinking skills • Ability to sit, use hands and fingers, and type for up to eight hours in a workday • Must understand and adhere to Confidentiality and Personal Health Information (PHI) Guidelines as stated in the Employee Handbook

🏖️ Benefits

• A wide range of health insurance options including medical, dental and vision • Strong bonus program • Robust 401k and company match • ESOP with annual stock allocations through a Qualified Retirement plan • Wellness program including financial incentives, chiropractic and massage services, and fitness stipends • Cohesive, family-based culture • Charitable contributions and volunteer time • Lots of celebrations!