Location: Remote (For Non-Local) or Hybrid (Local to NYC area)

Position Summary:

Responsible for the maintenance of prior authorization criteria, decision trees, decision notification templates, authorization parameters, verbiage, turnaround times, and other self-service functions in the prior authorization system to ensure internal department compliance and efficiency. Additionally, collaborates with external clients for delegated clinical PA systems services.

Position Responsibilities:

• Review of criteria updates provided by the formulary operations team (weekly, quarterly, and ad hoc) for all lines of business
• Responsible for updating PA criteria and associated product configurations in the prior authorization software within one week of receipt from formulary
• Build decision trees and question sets from PA criteria for prior authorization review
• Ensure PA questionnaires are configured with the appropriate authorization parameters for approval
• Identify areas of opportunity to improve prior authorization questionnaires based on provider responses and feedback from PA reviewers
• Mapping of prior authorization member and prescriber letter templates in the prior authorization system
• Batch-load testing within the prior authorization system of criteria and letter template configurations for accuracy
• 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
• 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
• Develops and maintains policies and procedures for creation and maintenance of clinical criteria questions and letter templates
• Identify PA reporting needs and collaborating with appropriate stakeholders to develop reports
• Respond to requests for clinical criteria from members and prescribers
• Attend formulary meetings and presentations as needed to stay abreast of all pertinent new information and changes
• Collaborate with external clients for delegated clinical PA systems services
• Manage setup, contracting, and relationships with prior authorization external vendors
• Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Minimum Qualifications:

• Active, unrestricted, pharmacist license required
• 3+ years health plan or PBM pharmacy experience required
• Strong clinical background and presentation skills required
• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel

Preferred Qualifications:

• Client facing experience preferred
• Experience managing utilization management (UM) criteria preferred

Base Salary: $125,000 - $145,000

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

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy 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 pharmacy 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.

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