Prior Authorization Technician I

Responsibilities

• Interprets and applies clinical criteria during the prior authorization review process and approves requests if applicable
• Utilizes member claims history during the prior authorization review process
• Makes outbound calls to obtain additional information needed to process prior authorization requests
• SUBMIT AUTHORIZATIONS TO PHARMACY AND MEDICAL CLAIMS PROCESSORS
• FORWARDS PRIOR AUTHORIZATION REQUESTS TO A PHARMACIST WHEN NECESSARY
• MAKES APPROPRIATE REFERRALS TO OTHER CLINICAL PROGRAMS
• ASSISTS IN DIRECTING APPROPRIATE REQUESTS TO IN NETWORK PROVIDERS
• AID IN ANSWERING INBOUND CALLS FROM THE CUSTOMER CARE CENTER WITH PRIOR AUTHORIZATION RELATED INQUIRIES
• ASSIST WITH APPEALS PROCESSING AS ASSIGNED
• ABILITY TO MULTITASK BETWEEN VARIOUS TASKS AND SYSTEMS WHILE MAINTAINING REQUIRED PRODUCTIVITY AND QUALITY LEVELS
• ABILITY TO MAKE CHANGES IN A FAST-PACED ENVIRONMENT
• STRONG KNOWLEDGE OF SPECIALTY AND NON-SPECIALTY PHARMACEUTICALS
• PERFORMS OTHER JOB-RELATED DUTIES AND PROJECTS AS ASSIGNED
• ATTENDS REQUIRED TRAINING ON AN ANNUAL BASIS.
• ADHERES TO CORPORATE AND DEPARTMENTAL POLICIES AND PROCEDURES.
• AVAILABLE TO WORK WEEKENDS AND HOLIDAYS.

Qualifications

• High School Diploma or equivalent required
• Active/current National Pharmacy Technician Certification (NHA or PTCB) or ability to obtain one within the first twelve (12) months of employment required
• Current/recent Pharmacy Benefit Manager (PBM), managed care, hospital pharmacy, long-term care (LTC) pharmacy, home infusion pharmacy, and/or retail pharmacy experience preferred

Skills

• Knowledge of pharmacy practices, procedures and precedents; ability to read and understand pharmaceutical information
• Working knowledge of drug dosage forms, drug strength, generic & trade name equivalent
• Demonstrate knowledge of Federal & State laws/regulations regarding provisions of pharmaceutical services
• Strong knowledge in specialty pharmaceuticals
• Ability to multi-task and prioritize work
• Comprehend and follow established office routines, policies and procedures
• Customer service and interpersonal skills
• Ability to adjust based on business/department needs
• Demonstrated courteous and professional behavior
• Proficient PC skills in a windows based environment
• Identify problems including complex issues and determine solutions, both independently or in a team/group setting

Benefits

• Flexible work solutions including remote options, hybrid work schedules, competitive pay
• Paid Time Off (PTO) including holidays and volunteer events
• health insurance coverage for you and your dependents on Day 1
• 401(k)
• tuition reimbursement
• and more.