Prior Authorization Technician I

Duties:

Reporting directly to the Supervisor, Prior Authorization Technicians, the Prior Authorization Technician I processes prior authorization requests received from providers, members, and pharmacies, including requests for high cost and specialty medications.

Essential Functions

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

Submits 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

Receives 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.

Skills:

1 to 3 Years required.

Previous PBM, managed care, hospital pharmacy, LTC pharmacy, Home Infusion pharmacy, retail pharmacy experience preferred.

Minimum 35 words per minute typing speed.

Education:

High School/GED Required

Certified Pharmacy Technician (PTCB or NHA). May be required to be licensed or certified in a specific state based upon contractual requirements and business need.

Requires working shift schedule outside standard business hours

Must remain in stationary position for long periods of time at desk or computer

Requires moving around office and non-office locations

Requires frequently moving about inside the office to access printer, files, and other materials/equipment

Operates a computer and other office equipment

Requires ability to Lift/Carry/Push/Pull - Typically less than 10 pounds