Pharmacy Prior Authorization Specialist

Prior Authorization Specialist

The Prior Authorization Specialist performs all duties outlined in the Pharmacy Technician job description and supports medication access for clinic patients by managing prescription prior authorizations for medications sent to both in-house and external pharmacies. This role works closely with providers, pharmacy staff, and insurance plans to obtain timely authorization approvals, resolve billing rejections, and identify formulary alternatives when appropriate. This position requires strong knowledge of medical terminology, prescription medications, and insurance billing processes. The role must maintain strict compliance with HIPAA and all applicable regulatory requirements while communicating effectively with patients, providers, and pharmacy staff. This is a position of trust.

Good verbal and written communication skills are required for this position. He or she must be detail oriented, organized and be a problem solver. He or she must be able to communicate effectively with patients, staff, and others, and contribute to a positive environment. The ability to communicate in Spanish, Creole, or both is a plus.

Key Responsibilities:

1. Perform all duties outlined in the Pharmacy Technician job description.
2. Manage prescription prior authorizations for clinic patients for medications filled at both in-house and external pharmacies.
3. Work closely with providers to obtain necessary clinical documentation and complete prior authorization requests accurately and efficiently.
4. Review formulary requirements and communicate therapeutic or formulary alternatives to providers when appropriate.
5. Monitor pharmacy insurance rejection queues and assist in resolving billing issues related to prior authorization requirements.
6. Promote appropriate utilization of the in-house pharmacy by coordinating with providers and patients to facilitate prescription transfers when clinically appropriate and permitted by patient choice.
7. Communicate with patients regarding authorization status, insurance requirements, and medication access.
8. Coordinate with pharmacy staff, providers, and insurance plans to ensure timely approval and dispensing of medications.
9. Provide phone support for pharmacy operations when needed.
10. Assist pharmacy leadership with operational support and other duties as assigned.

Education & Training:

1. High school diploma or GED required.
2. Active Florida Pharmacy Technician License in good standing required.
3. Proficiency in pharmacy management systems, EMR systems, Microsoft Office applications, and electronic billing platforms.

Experience:

1. Minimum of two (5) years of experience in a community health center, retail/community pharmacy, or hospital pharmacy setting preferred.
2. Knowledge of the 340B Drug Pricing Program preferred.
3. Experience with third-party pharmacy billing, prior authorizations, and claims resolution preferred.

Physical Requirements:

1. Ability to stand, sit, and walk for extended periods of time
2. Ability to lift and carry objects weighing up to 20 pounds
3. Ability to communicate effectively using written and spoken English
4. Demonstrated visual and auditory acuity necessary to perform job duties.

Additional Requirements:

1. Must maintain all required vaccinations in accordance with organizational policy.
2. Annual tuberculosis screening (PPD or equivalent) required.
3. Compliance with the organization's influenza vaccination policy.
4. Successful completion of a Level 2 background screening required.
5. Travel to other clinic locations as required.

WFHC reserves the right to change or modify the job description, including but not limited to Major Responsibilities, Education, Certification, and Physical Requirements.