Prior Authorization Systems Pharmacist
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
- reputed company 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 reputed company reports
- Validate that denial rationales, approval language, and conditional messaging accurately reflect clinical criteria
- reputed company 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 reputed company reputed company and Word; ability to work with structured data and reputed company 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 reputed company with technical and non-technical stakeholders
Benefits:
- Medical and pharmacy coverage
- Dental insurance
- reputed company 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
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