Prior Authorization Clinical Criteria & Policy Coordinator

Description

TrueScripts Management Services is a pharmacist-founded, fully transparent Prescription Benefit Manager that has been revolutionizing the PBM industry since 2014. Our mission is to build lasting relationships by providing prescription benefit expertise at a personal and customized level to ensure optimum value at the lowest possible cost. We are committed to lowering prescription drug spending, achieving clinically effective outcomes, and always delivering Amazing Care. Did we mention Amazing Care? Good! Because this is so much more than just our tagline. It is the foundation upon which our business was built. We believe that Amazing Care starts from within, and our culture is reflective of this philosophy.

Our team members enjoy:

• A wide range of health insurance options including medical, dental and vision
• Strong bonus program
• A robust 401k and company match
• Truescripts is transitioning to an ESOP, a team member owned company! Each year team members are allocated shares of stock through our ESOP, a Qualified Retirement plan!
• A wellness program including financial incentives, chiropractic and massage services, and fitness stipends
• A cohesive, family-based culture
• Charitable contributions and volunteer time
• Lots of celebrations!

Ok, enough about us. Here’s what we need from you: A future team members' values need to align with TrueScripts' core values of Integrity, Respect, Innovation, and Service. This match in value systems is critical for our team's chemistry and continued success. Our culture is positive, and our people possess a ‘can do, proactive attitude. Honesty and transparency are the foundation that we build upon. What sets us apart from our competitors is the programs that we bring, the education that we provide, and the utmost respect for clients and their members to assist them when and where needed.

What you’ll do

This role is responsible for drafting, gaining approval for, and maintaining the clinical criteria and question sets used across TrueScripts' prior authorization (PA) process — from initial drafting through pharmacist and policy committee approval, prior authorization platform build and testing, production deployment, and ongoing maintenance. The incumbent also owns related PA forms and correspondence and state-specific requirements, while keeping the Prior Authorization Coordinator Team informed and enabled.

Clinical Criteria Drafting

• Draft clinical criteria policies and question sets for medications requiring prior authorization, informed by current FDA labeling, clinical guidelines, and drug compendia.

• Perform initial quality checks on drafted content to ensure clinical accuracy and alignment with current guidelines before submission for pharmacist review.

• Use dashboards and reporting, with support from the Prior Authorization Coordinator Team, to proactively identify medications needing new or updated criteria.

Approval & Governance

• Submit draft criteria for formal review and approval, first by internal pharmacists, then by the policy committee.

• Prepare summary materials and supporting documentation for policy committee review and presentations.

• Maintain a master tracking log of all criteria in Confluence, with support from the Quality Committee Champion, including approval and effective dates, next scheduled review date, and version history, to ensure the annual (or sooner) review cadence is met.

Prior Authorization Platform Build, Testing & Deployment

• Build approved clinical criteria and question sets into the prior authorization platform.

• Develop and execute test cases to validate question logic, branching, and outcomes prior to production release.

• Migrate approved, tested policies to the production environment.

• Maintain version control across draft, approved, and production policies to avoid discrepancies.

Forms, Letters & State-Specific Requirements

• Build and maintain PA-related forms (e.g., prescriber fax forms, clinical information requests) and correspondence templates (approval letters, denial letters, appeal rights notices) within the prior authorization platform.

• As guided by Compliance, research and incorporate state-specific requirements — turnaround times, required notice language, appeal rights, step therapy override laws — into criteria, forms, and letters.

• As guided by Compliance, implement state-specific prior authorization requirements within the prior authorization platform, ensuring criteria, forms, and letters reflect each state's rules.

• Maintain a reference log of state-specific requirements by state and client/plan, updating it as advised by Compliance of regulatory or legislative changes.

• Implement member notification for prior authorization determinations — including approvals, denials, and appeal rights — and ensure the process remains compliant going forward.

Documentation & Knowledge Management

• Serve as steward of the criteria repository in Confluence, ensuring a single, current source of truth exists for all approved criteria.

• Maintain change logs and archive retired or superseded criteria while preserving version history.

• Create and update job aids by summarizing new or revised criteria for the Prior Authorization Coordinator Team.

Team Communication & Enablement

• Communicate new and updated criteria to the Prior Authorization Coordinator Team ahead of go-live, including any workflow or documentation changes.

• Serve as the subject matter resource for the team on how specific criteria should be applied.

• Communicate relevant updates to other internal stakeholders (e.g., Clinical, Compliance, Client Services) as needed.

Compliance & Audit Support

• Support internal and external audits (client, URAC/NCQA accreditation, state regulatory) by providing documentation showing criteria are current, evidence-based, and properly approved.

• Audit prior authorization criteria effective dates year over year to account for plan changes (e.g., plan renewals), ensuring criteria remain aligned with current plan parameters.

• Assist with appeals or grievance reviews by supplying clinical criteria documentation and rationale.

Ad Hoc / Urgent Builds

• Manage expedited criteria development for urgent situations, such as a new drug requiring immediate PA criteria outside the normal review cycle.

• Perform other duties as assigned.

Requirements

Qualifications   

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

• Pharmacy technician experience strongly preferred.

• Experience with pharmacy prior authorizations, PBM operations, or clinical criteria drafting strongly preferred.

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

• Excellent written communication skills for policy drafting, documentation, and cross-team communication.

• Experience with a prior authorization platform or similar processing/workflow software preferred.

• Familiarity with Confluence or similar knowledge management tools.

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

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

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

• Proactive, detail-oriented mindset with strong problem-solving and analytical thinking skills.

Physical Demands:

While performing the duties of this job, the employee is frequently required to sit, use hands and fingers and to type for up to eight hours in a workday.

All employees of TrueScripts must understand and adhere to Confidentiality and Personal Health Information (PHI) Guidelines as stated in the Employee Handbook.