Prior Authorization Clinical Criteria – Policy Coordinator

This is a fully remote position, open to applicants in Washington.

📋 Description

• Create clinical criteria policies and question sets for medications that require prior authorization, utilizing FDA labeling, clinical guidelines, and drug compendia.

• Conduct initial quality assessments to ensure clinical accuracy and alignment with guidelines.

• Identify medications that require new or updated criteria by utilizing dashboards and reporting tools.

• Present criteria for review and approval by pharmacists and the policy committee.

• Compile summary materials and supporting documents for the policy committee's evaluation.

• Maintain the master criteria tracking log within Confluence, including details on approvals, effective dates, review dates, and version history.

• Develop approved criteria and question sets within the prior authorization platform.

• Design and implement test cases for question logic, branching, and outcomes.

• Transition approved and tested policies into production while managing version control.

• Create and maintain prior authorization forms and correspondence templates.

• Investigate and integrate state-specific prior authorization requirements under Compliance guidance.

• Keep reference logs of state-specific requirements organized by state and client/plan.

• Implement compliant notifications to members regarding approvals, denials, and appeal rights.

• Oversee the Confluence criteria repository and archive any retired or superseded criteria.

• Develop and update job aids for the Prior Authorization Coordinator Team.

• Relay updates on criteria and workflow changes to internal teams and stakeholders.

• Act as a subject matter expert on criteria application.

• Assist with audits by clients, URAC/NCQA, and state regulatory authorities.

• Review criteria effective dates and ensure alignment with plan parameters.

• Provide criteria documentation and rationale to support appeals or grievance reviews.

• Manage expedited criteria development for urgent requirements.

• Carry out other assigned duties.

⛳️ Requirements

• High school diploma is required; a two-year degree is preferred.

• Experience as a pharmacy technician is highly preferred.

• Strongly preferred experience in pharmacy prior authorizations, PBM operations, or drafting clinical criteria.

• Strong research abilities, including the capacity to interpret FDA labeling, clinical guidelines, and drug literature.

• Excellent written communication skills for drafting policies, documentation, and interdepartmental communication.

• Preferred experience with a prior authorization platform or similar processing/workflow software.

• Familiarity with Confluence or comparable knowledge management tools.

• Strong organizational skills and attention to detail; ability to manage multiple criteria projects concurrently.

• Proficiency in Microsoft Office 365 (Word, Excel, Outlook, etc.).

• Ability to work independently while closely collaborating with pharmacists, the policy committee, and the Prior Authorization Coordinator Team.

• A proactive, detail-oriented approach with strong problem-solving and analytical skills.

• Capability to sit, use hands and fingers, and type for up to eight hours during a workday.

• Must understand and comply with Confidentiality and Personal Health Information (PHI) Guidelines as outlined in the Employee Handbook.

🏝️ Benefits

• A diverse array of health insurance options, including medical, dental, and vision coverage.

• A strong bonus program.

• A robust 401k plan with company matching.

• An Employee Stock Ownership Plan (ESOP) with annual stock allocations through a Qualified Retirement plan.

• A wellness program featuring financial incentives, chiropractic and massage services, and fitness stipends.

• A supportive, family-oriented culture.

• Opportunities for charitable contributions and volunteer time.

• Numerous celebrations throughout the year!