Technician I, Prior Authorizations

About the role

You’ll take in-bound calls from providers, pharmacies, members, and others, providing professional and courteous phone assistance through the criteria-based prior authorization process. Maintain complete, timely, and accurate documentation of reviews. Transfer all clinical questions, escalations, and judgment calls to the pharmacist team. Assist with other duties as needed, including outbound calls, reviewing and processing Prior Auths received via fax and ePA, monitoring and responding to inquiries via department mailboxes, and other tasks assigned by the leadership team.

Responsibilities

• Enter prior authorization requests submitted by healthcare providers, ensuring all required documentation is complete and accurate.
• Verify insurance coverage to determine if prior authorization is required for specific medical procedures, treatments, or medications.
• Inspect medical records and clinical documentation to assess the medical necessity and appropriateness of the requested services or treatments.
• Assist in the preparation and submission of appeals for denied or rejected prior authorization requests, including gathering necessary supporting documentation.
• Document relevant information into electronic systems, including patient details, medical codes, and prior authorization status.
• Communicate with team members and supervisors to identify process inefficiencies and propose solutions to streamline prior authorization operations.
• Communicate with healthcare providers to obtain additional information, clarify documentation, and relay prior authorization decisions or requirements.
• Maintain awareness of updated industry regulations, medical coding guidelines, and changes in prior authorization requirements by participating in training sessions and knowledge-sharing activities.
• Ensure adherence to regulatory guidelines, company policies, and industry standards during the prior authorization process.

Requirements

• 6 months of customer service or pharmacy technician experience.
• Regular and predictable attendance.
• Ability to work mandatory overtime or extended work weeks when needed.
• Ability to travel when needed.
• Effectively manage work volume by handling inbound calls and fax requests with appropriate, courteous, and professional behavior based on established standards.
• Comply with departmental, company, state, and federal requirements when processing information to ensure accuracy for internal and external customers.

Qualifications

• High school diploma or equivalent GED.

Physical Requirements

• Long periods of sitting (up to 100% of the time).
• Talking on the phone for extended periods (90-100% of the time).
• Reading a computer screen for extended periods (100% of the time).

Work Environment

This is a home office position. Your workspace must ensure compliance with CVS Health privacy and security policies and procedures. Information on your computer screen must not be accessible or viewable by others. Telephone conversations involving confidential information must not be audible to others present in the home. Any CVS equipment or documents may not be accessible by others inside or outside of business hours. When a computer is not in use, it should remain locked or off to secure confidential information.

Schedule

• Full-time, 40 hours per week.

Pay

The typical pay range for this role is $17.00 - $28.46 per hour. This range represents the base hourly rate for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography, and other relevant factors. This position is also eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range.

Benefits

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. Benefits include:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.