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
- 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
- Collaborate cross-functionally to support system improvements, process optimization, and implementation initiatives
- Identify opportunities for workflow efficiency, automation, and data quality improvement within the PA process
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)
- High attention to detail with a focus on data accuracy and configuration quality
- Proficiency in Microsoft Excel and Word; ability to work with structured data