Prior Authorization Technician

Prior Authorization Technician I

Reporting directly to the Supervisor of Prior Authorization Technicians, the Prior Authorization Technician I is responsible for processing prior authorization requests received from providers, members, and pharmacies, including requests involving high-cost and specialty medications. The role requires strong pharmaceutical knowledge, attention to detail, multitasking abilities, and effective communication while maintaining required productivity and quality standards.

Responsibilities

• Review and process prior authorization requests using established clinical criteria and approve requests when appropriate.
• Utilize member claims history and other available information during the authorization review process.
• Make outbound calls to obtain additional information required to process authorization requests.
• Submit approved authorizations to pharmacy and medical claims processors.
• Forward requests to a pharmacist for clinical review when necessary.
• Make appropriate referrals to other clinical programs.
• Direct eligible requests to appropriate in-network providers.
• Respond to inbound calls from the Customer Care Center regarding prior authorization inquiries.
• Assist with appeals processing as assigned.
• Manage multiple tasks and systems simultaneously while maintaining productivity and quality standards.
• Adapt effectively to a fast-paced and changing work environment.
• Apply knowledge of specialty and non-specialty pharmaceuticals in daily activities.
• Attend required annual training and comply with all corporate and departmental policies and procedures.
• Perform other job-related duties and projects as assigned.
• Maintain availability to work weekends and holidays as required.

Qualifications & Skills

• 13 years of relevant experience required.
• Previous experience in PBM, managed care, hospital pharmacy, long-term care (LTC) pharmacy, home infusion pharmacy, or retail pharmacy is preferred.
• Strong knowledge of specialty and non-specialty pharmaceuticals.
• Minimum typing speed of 35 words per minute.
• Strong attention to detail, communication, organization, and multitasking skills.
• Ability to work effectively across multiple systems and processes while maintaining accuracy and productivity.

Education & Certification

• High School Diploma or GED required.
• Certified Pharmacy Technician (CPhT) certification through PTCB or NHA required.
• May be required to maintain pharmacy technician licensure or certification in a specific state based on contractual requirements and business needs.

Work Environment & Physical Requirements

• Ability to work shifts outside standard business hours, including weekends and holidays as required.
• Ability to remain stationary at a desk or computer for extended periods.
• Ability to move throughout office and non-office locations as needed.
• Frequently move within the office to access printers, files, equipment, and other materials.
• Ability to operate computers and standard office equipment.
• Ability to lift, carry, push, or pull items typically weighing less than 10 pounds.