Manager, Prior Authorization Systems Pharmacist
Capital Rx
Position Summary:
We are seeking a licensed pharmacist with leadership experience to manage a team responsible for the development, implementation, and maintenance of clinical criteria and prior authorization (PA) system configurations. This role will oversee the creation of utilization management policies, decision tree logic, and member-facing communications to ensure compliance, efficiency, and clinical accuracy. The ideal candidate brings a strategic mindset, strong clinical knowledge, and a passion for leading high-performing teams in a dynamic environment.
Position Responsibilities:
- Lead and mentor a team of pharmacists and analysts responsible for PA criteria development, system configuration, and letter template management.
- Oversee the creation and maintenance of clinical criteria and decision trees based on evidence-based guidelines and plan benefits.
- Lead initiatives to improve member and provider communication through clear, compliant, and user-friendly denial and approval language.
- Ensure timely and accurate implementation of formulary updates, new drug reviews, and regulatory changes across all lines of business.
- Collaborate with cross-functional teams including Formulary, Benefits, Product/Development, Regulatory/Compliance, and Prior Authorization Operations to optimize workflows and ensure alignment.
- Drive continuous improvement in PA system configuration, including automation, self-service tools, and turnaround time (TAT) compliance.
- Monitor team performance, provide coaching and development, and ensure adherence to quality and compliance standards.
- Serve as a subject matter expert for internal and external stakeholders regarding PA criteria, system capabilities, and regulatory requirements.
- Review prior authorization, appeal, and override requests as needed.
Qualifications:
- Active, unrestricted pharmacist license (PharmD or BPharm required)
- 5+ years of experience in prior authorization or utilization management, with at least 2 years in a leadership or supervisory role
- Strong understanding of clinical criteria development, formulary management, and benefit design
- Experience with PA system configuration and letter template mapping preferred
- Excellent communication, writing, and organizational skills
- Proficient in Microsoft Office Suite, especially Excel; experience with PA platforms and data visualization tools a plus
This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
About Capital Rx
Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi®, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.
Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.