Pharmacy Prior Authorization Coordinator I

About the role

The Pharmacy Prior Authorization Coordinator I is responsible for delivering high-quality customer service by answering and managing calls from members, provider offices, and pharmacies. This role supports the processing of prior authorization (PA) requests for pharmacy benefit medications, ensuring accuracy, compliance with regulatory and clinical guidelines, and alignment with client performance standards.

Responsibilities

• Verify member insurance eligibility and pharmacy benefit coverage.
• Communicate with members and providers regarding basic pharmacy inquiries and PA status.
• Accurately enter and process prior authorization (PA) requests into the system, prioritizing appropriately.
• Ensure PA requests are processed and finalized within required turnaround times (TAT) and client Performance Guarantees (PGs), using provided clinical guidelines.
• Review medication history and assess for formulary alternatives and “tried and failed” drugs.
• Document all relevant PA information clearly and accurately, including approval or denial rationale.
• Send PA status updates to providers and pharmacies via fax or other required methods.
• Adhere to defined roles and responsibilities related to clinical decision-making boundaries.
• Maintain strict confidentiality and security of all member and PA-related data, following applicable protocols for data handling and storage.

Requirements

• High School Diploma or GED strongly preferred.
• 1 year healthcare experience required.

Qualifications

• Strong communication and problem-solving skills.
• Ability to prioritize tasks and meet deadlines.
• Familiarity with healthcare regulations and clinical guidelines.
• Proficiency in Microsoft Office applications.

Skills

• Excellent verbal and written communication skills.
• Ability to manage multiple tasks and prioritize effectively.
• Knowledge of healthcare regulations and clinical guidelines.
• Proficiency in Microsoft Office applications.

Benefits

• Caring For Your Family and Your Career
• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down – $10,000
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Pay

The base pay rate for Full Time employment is: $19.04/HR – $31.73/HR. Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Schedule

Shift: Monday- Friday from 8:00am to 8:00pm and must be flexible to work on weekends.