Prior Authorization Technician I

Shift

• Position is remote. No time zone preference but shift times offered will be in EST time so candidates will need to adjust accordingly if in a different time zone.
• Shift Schedule: 8:30am-5:00pm EST, 9:00am-5:30pm EST, or 9:30am-6:00pm EST

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.
• PRIOR AUTHORIZATION PROCESSING
• CLINICAL CRITERIA INTERPRETATION
• MEMBER CLAIMS HISTORY UTILIZATION
• OUTBOUND CALLING
• AUTHORIZATION SUBMISSION
• Additional
• REFERRAL MANAGEMENT
• APPEALS PROCESSING
• MULTITASKING
• ADAPTABILITY
• SPECIALTY PHARMACEUTICALS KNOWLEDGE
• NON-SPECIALTY PHARMACEUTICALS KNOWLEDGE
• PBM EXPERIENCE
• MANAGED CARE EXPERIENCE
• HOSPITAL PHARMACY EXPERIENCE
• LTC PHARMACY EXPERIENCE
• HOME INFUSION PHARMACY EXPERIENCE
• RETAIL PHARMACY EXPERIENCE

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