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.
Position Summary
Responsible for the design, configuration, and quality assurance of prior authorization (PA) criteria, including decision trees, authorization parameters, and member/provider communications within the PA system. Ensures clinical intent is accurately translated into compliant, efficient system logic through structured QA/QC and validation processes. Collaborates with internal teams and external clients to support delegated PA services and drive system optimization.
Position Responsibilities
- Build decision trees and question sets from PA criteria for prior authorization review.
- Perform comprehensive quality control (QC) review of decision trees, questionnaires, and authorization logic to ensure alignment with clinical intent, regulatory requirements, and business rules.
- Conduct quality assurance (QA) validation of configured criteria and decision paths, including scenario-based testing to confirm expected outcomes.
- Ensure PA questionnaires are configured with the appropriate authorization parameters for approval.
- Collaborate with external clients for delegated clinical PA systems services and manage relationships with external vendors.
- Map prior authorization member and prescriber letter templates in the system, performing QC/QA reviews for accuracy and regulatory compliance.
- Develop and maintain policies and procedures for the creation of clinical criteria questions and letter templates.
- Establish and maintain QA/QC standards, documentation, and audit processes.
- Identify PA reporting needs and collaborate with stakeholders to develop reports.
Minimum Qualifications
- Active, unrestricted, pharmacist license required.
- 3+ years health plan or PBM pharmacy experience.
- Strong clinical background and presentation skills.
- Proficiency in Microsoft Excel and Word; ability to work with structured data.
- 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 clearly with technical and non-technical stakeholders.
Preferred Qualifications
- Client-facing experience.
- Experience managing utilization management (UM) criteria.