Senior Pharmacy PA/Appeals Technician

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities.

About the role

The essential functions of a Senior Pharmacy PA/Appeals Technician include supporting the prior authorization and appeals process by providing accurate, timely, and professional service to members, providers, pharmacists, and internal business partners. This role is responsible for receiving, researching, documenting, and processing prior authorization requests for formulary and non-formulary medications through multiple intake channels, including phone, fax, and electronic systems.

Responsibilities

• Manage a high volume of inbound and outbound calls, averaging 50+ daily, while maintaining professionalism, accuracy, and customer service expectations
• Respond to prior authorization inquiries and requests from providers, pharmacies, members, and internal partners using approved scripts, reference materials, job aids, policies, and procedures
• Review and process prior authorization requests through multiple computer systems, ensuring required information is complete, accurate, and documented in accordance with compliance, regulatory, client, and business requirements
• Research formulary, benefit, medication, eligibility, and plan-specific information to help resolve prior authorization questions, benefit issues, and case-processing barriers
• Gather and verify member, provider, prescriber, pharmacy, medication, diagnosis, and clinical support information needed for pharmacist consultation or clinical review
• Identify missing or incomplete information and take appropriate follow-up action, including outbound calls or routing to the appropriate team, pharmacist, or clinician when needed
• Prioritize work to support required turnaround times for standard, expedited, urgent, and client-specific prior authorization requests
• Maintain productivity, quality, schedule adherence, attendance, and documentation standards in a fast-paced, metric-driven environment
• Resolve issues and complaints in a timely, professional manner and escalate concerns when additional support, clinical review, or leadership guidance is required
• Apply sharp attention to detail when reviewing prior authorization requests, using established criteria and guidelines to support accurate and compliant case processing
• Accurately document call details, case actions, approvals, denials, transfers, escalations, and follow-up activity in the appropriate systems
• Protect confidential information and handle protected health information in accordance with privacy, security, HIPAA, regulatory, and company requirements
• Use sound judgment to recognize when a request requires pharmacist review, clinical clarification, additional documentation, or escalation to leadership
• Adapt to changing workflows, client requirements, system updates, job aids, and business priorities while maintaining accuracy and service standards
• Perform other duties as assigned by management

Patient Safety & Quality Initiatives

• Support patient safety and quality by completing work accurately, documenting thoroughly, and following approved criteria, policies, procedures, and regulatory requirements
• Identify and escalate potential patient safety, medication, benefit, system, privacy, or quality concerns in a timely manner
• Maintain a safe and secure workspace and promptly notify leadership if equipment, system access, information security, or workspace conditions may affect safe and compliant work
• Participate in quality improvement efforts by applying feedback, correcting errors, and consistently following updated job aids, workflows, and standard operating procedures

Requirements

• Active and unrestricted Pharmacy Technician licensure, registration, or certification as required by the state of residence and business needs
• Pharmacy Technician Certification Board (PTCB) or ExCPT - Pharmacy Technician Certification through the National Healthcareer Association (NHA), or other approved prior authorization or pharmacy technician certification, as accepted by the business
• State Board of Pharmacy licensure or registration in state of residence, if required
• 6+ months of experience in customer service, customer relations, healthcare, pharmacy, call center, or direct interaction with healthcare professionals
• Beginner level of proficiency with Microsoft Excel, Word, Outlook, and Teams, including the ability to create, edit, save, send, and manage basic documents, spreadsheets, emails, and communications
• Beginner level of ability to navigate multiple systems, screens, job aids, knowledge articles, and electronic workflows while maintaining accuracy during calls and case processing
• Ability to work any shift within the 5:00 AM to 12:00 AM timeframe, including flexible hours, overtime, weekends, and holidays as required by business needs

Preferred Qualifications

• Experience with prior authorization, appeals, pharmacy benefit management, prescription drug benefits, formulary review, pharmacy claims, or healthcare coverage processes
• Experience working in a high-volume, production-based, quality-monitored, or compliance-driven environment
• Knowledge of Medicare Part D, commercial, Medicaid, exchange, or client-specific pharmacy benefit requirements
• Knowledge of call center systems such as CMS, IEX, CTI, TCS, or similar telephony, workforce, and case-management platforms
• Familiarity with pharmacy terminology, medication names, brand and generic drug names, SIG codes, benefit terminology, and healthcare documentation standards

Skills

• Strong verbal and written communication skills with the ability to explain information clearly, professionally, and accurately to providers, members, pharmacists, and internal partners
• Strong attention to detail and ability to apply established criteria, workflows, and documentation standards consistently
• Ability to manage competing priorities, follow through on assigned tasks, and meet deadlines in a fast-paced, metric-driven environment
• Critical thinking, problem-solving, and sound judgment to identify incomplete information, workflow barriers, compliance concerns, or situations requiring escalation
• Ability to accept feedback, adjust performance, and support continuous improvement in quality, productivity, service, and compliance outcomes

Physical Requirements and Work Environment

• Frequent speaking and listening using a headset; sitting for extended periods; use of hands and fingers across a keyboard and mouse; and extended periods working at a computer
• Reliable high-speed home internet access, with the ability to use a hard-wired ethernet connection when required
• Secure, private home workspace that supports protection of confidential information and compliance with company telecommuter, privacy, and security policies
• Intermediate comfort using a computer, including keyboard and mouse navigation, opening applications, switching between multiple systems and screens, and learning new tools or workflows

Benefits

• Paid Time Off (accrued from first pay period) plus 8 paid holidays
• Medical plan options along with participation in a Health Spending Account or Health Savings Account
• Dental, Vision, Life & AD&D Insurance along with Short-term and Long-Term Disability coverage
• 401(k) Savings Plan and Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

Pay

The hourly pay for this role will range from $18 - $32 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, and certifications.