Prior Authorization Technician I

Responsibilities

• Report directly to the Supervisor, Prior Authorization Technicians.
• Process prior authorization requests received from providers, members, and pharmacies, including high‑cost and specialty medications.
• Interpret and apply clinical criteria during the prior authorization review process and approve requests when applicable.
• Utilize member claims history during the prior authorization review process.
• Make outbound calls to obtain additional information needed to process prior authorization requests.
• Submit authorizations to pharmacy and medical claims processors.
• Forward prior authorization requests to a pharmacist when necessary.
• Make appropriate referrals to other clinical programs.
• Assist in directing appropriate requests to in‑network providers.
• Receive inbound calls from the customer care center with prior‑authorization‑related inquiries.
• Assist with appeals processing as assigned.
• Multitask between various tasks and systems while maintaining required productivity and quality levels.
• Adapt to changes in a fast‑paced environment.
• Maintain strong knowledge of specialty and non‑specialty pharmaceuticals.
• Perform other job‑related duties and projects as assigned.
• Attend required training on an annual basis and adhere to corporate and departmental policies and procedures.
• Be available to work weekends and holidays.

Skills

• 1 to 3 years of relevant experience required.
• Previous experience in PBM, managed care, hospital pharmacy, LTC pharmacy, home infusion pharmacy, or retail pharmacy preferred.
• Minimum typing speed of 35 words per minute.

Education & Certifications

• High School diploma or GED required.
• Certified Pharmacy Technician (PTCB or NHA) required.
• May be required to hold a state‑specific license or certification based on contractual requirements and business need.

Additional Requirements

• Work schedule may include shifts outside standard business hours.
• Must remain in a stationary position for long periods at a desk or computer.
• May need to move around office and non‑office locations, frequently accessing printers, files, and other materials/equipment.
• Operate a computer and other office equipment.
• Ability to lift/carry/push/pull typically less than 10 pounds.