Clinical Coordinator

• Draft clinical criteria policies and question sets for medications requiring prior authorization using FDA labeling, clinical guidelines, and drug compendia
• Perform initial quality checks for clinical accuracy and guideline alignment
• Identify medications needing new or updated criteria using dashboards and reporting
• Submit criteria for pharmacist and policy committee review and approval
• Prepare summary materials and supporting documentation for policy committee review
• Maintain the master criteria tracking log in Confluence, including approvals, effective dates, review dates, and version history
• Build approved criteria and question sets in the prior authorization platform
• Develop and execute test cases for question logic, branching, and outcomes
• Migrate approved and tested policies to production and maintain version control
• Build and maintain prior authorization forms and correspondence templates
• Research and incorporate state-specific prior authorization requirements under Compliance guidance
• Maintain reference logs of state-specific requirements by state and client/plan
• Implement compliant member notifications for approvals, denials, and appeal rights
• Steward the Confluence criteria repository and archive retired or superseded criteria
• Create and update job aids for the Prior Authorization Coordinator Team
• Communicate criteria updates and workflow changes to internal teams and stakeholders
• Serve as a subject matter resource on criteria application
• Support client, URAC/NCQA, and state regulatory audits
• Audit criteria effective dates and alignment with plan parameters
• Assist with appeals or grievance reviews by providing criteria documentation and rationale
• Manage expedited criteria development for urgent situations
• Perform other duties as assigned

Clinical Coordinator jobs in Washington

Prior Authorization Clinical Criteria – Policy Coordinator