Position Summary:

We are seeking a licensed pharmacist to support the development and maintenance of clinical criteria and prior authorization system configurations. This role is responsible for writing utilization management policies, building decision trees, mapping letter templates, and creating template language for member-friendly communications. The ideal candidate will bring a detail-oriented mindset, excellent writing skills, and a deep understanding of prior authorization workflows to support efficient and accurate processes.

Position Responsibilities:

• Build decision trees and question sets from PA criteria for prior authorization review
• Writing utilization management criteria policies based on clinical practice guidelines and plan benefit setup
• Mapping of prior authorization notification letter templates in the prior authorization system
• Batch-load testing within the prior authorization system of criteria and letter template configurations for accuracy
• Review of criteria updates provided by the formulary operations team (weekly, quarterly, and ad hoc) for all lines of business
• Weekly review and evaluation of the Medispan new drug to market report for changes that may cause disruption for members with current active prior authorizations
• Responsible for updating PA criteria and associated product configurations in the prior authorization software within one week of receipt from formulary
• Creation and maintenance of Commercial and Government denial verbiage templates to remain up to date with criteria changes and as needed to improve reviewer efficiency
• Presents PA team members with significant changes to criteria or approval parameters, and responds to internal team member issues related to criteria questions and setup
• Manages prior authorization self-service functions and configurations including, but not limited to, TAT configurations, denial verbiage templates, and fax back messaging to ensure compliance with state, federal, and other regulations
• Works with the prior authorization software development team to identify and enhance the setup of criteria mapping and other self-service functions for review efficiency and compliance
• Respond to requests for clinical criteria from members and prescribers
• Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria.

Qualifications:

• Active, unrestricted, pharmacist license
• Bachelor’s or Doctor of Pharmacy degree
• 2+ years of prior authorization review experience required
• Experience managing clinical criteria strongly preferred
• Formulary experience preferred
• Strong communication, writing, and organizational skills Proficient in Microsoft office Suite with emphasis on Microsoft Excel

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.