Prior Authorization Systems Technician

Location: Hybrid (Local to New York, NY, Charlotte, NC or Denver, CO area)

Position Summary

Responsible for the maintenance, configuration, and validation of prior authorization (PA) criteria, decision trees, and communication templates within the PA system. Supports accurate translation of clinical requirements into system logic through routine updates, testing, and quality checks. Partners with pharmacists and cross-functional teams to ensure data integrity, resolve issues, and maintain efficient, compliant PA operations.

Position Responsibilities:

• Evaluate and operationalize weekly formulary and utilization management (UM) updates, including criteria changes, product additions, and retirements
• Maintain and configure prior authorization (PA) criteria, rules, and source documentation within the PA platform, ensuring alignment with clinical and formulary intent
• Experience creating or maintaining prior authorization decision trees, rules engines, or clinical workflows strongly preferred
• Ability to interpret clinical guidelines and translate them into structured logic or system configurations
• Experience documenting clinical rationale or supporting materials for utilization management criteria preferred
• Perform structured validation and quality assurance (QA) of criteria builds, letter templates, and system configurations prior to deployment
• Partner with Formulary Operations and Clinical teams to identify and resolve discrepancies in criteria logic, coding, or documentation
• Support new drug-to-market implementations, including analysis and updates for GPI, NDC, and other product identifiers impacting existing authorizations
• Maintain and enhance letter templates and automated communications to ensure regulatory compliance and operational consistency
• Execute and support batch load testing, regression testing, and release validation for system updates and enhancements
• Act as a subject matter resource for PA criteria setup, troubleshooting issues, and answering internal inquiries from operations, pharmacists, and business partners
• Monitor and triage system or configuration issues, escalating appropriately and partnering with IT/vendor teams for resolution
• Conduct intake and pre-review preparation of PA cases by validating member, provider, and clinical information against guideline requirements
• Proactively obtain and organize clinical documentation to ensure completeness and readiness for pharmacist or clinician review
• Collaborate cross-functionally with Clinical, Operations, IT, and Business teams to support system improvements, process optimization, and implementation initiatives
• Identify opportunities for workflow efficiency, automation, and data quality improvement within the PA process
• Adapt quickly to shifting priorities and support multiple concurrent initiatives in a fast-paced environment

Required Qualifications:

• 4+ years of pharmacy technician experience in a PBM, health plan, or clinical pharmacy environment
• Demonstrated experience working with prior authorization systems, UM criteria, or clinical rule configuration
• National Certified Pharmacy Technician (CPhT) certification required
• Strong understanding of prior authorization workflows, clinical guidelines, and formulary management
• Experience supporting system testing (UAT, regression, or configuration validation) preferred
• 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
• Proficiency in Microsoft Excel and Word; ability to work with structured data and perform basic analysis (e.g., validation, comparisons, tracking updates)
• Experience working cross-functionally with clinical, operational, and/or IT teams preferred
• Bachelor’s degree or equivalent combination of education and experience preferred

*Depending on the changing needs of the business, you may be required to work rotating weekends and/ or participate in an on-call schedule in the future.

This range represents the low and high end of the anticipated base salary range. The actual base salary will depend on several factors such as: experience, knowledge, and skills, and location of the job.

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

Benefits

Judi Health provides all full-time and part-time benefit-eligible employees with the ability to elect medical and pharmacy coverage, dental insurance, vision insurance, accidental injury insurance, critical illness insurance, hospital indemnity insurance, and flexible spending accounts. Full-time employees also have access to a health savings account, voluntary life insurance, and voluntary accidental death and dismemberment insurance for themselves and their eligible dependents.

Judi Health provides full-time employees with the following benefits at no cost to the employee: basic life insurance, basic accidental death and dismemberment insurance, paid time off, sick time, holidays, short-term disability, long-term disability, an employee assistance program, and a wellness program. Full-time employees are also eligible for a 401(k) plan with company match after one year of full-time employment.

About Judi Health

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers,
• Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and
• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform.

Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve.

We 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.