Pharmacy Technician

Pharmacy Technician

The Pharmacy Technician supports multiple pharmacy operations areas, including formulary management, pharmacy audit and recovery, pharmacy service center, Medicare Part D and Part B, appeals, state health programs pharmacy operations, prior authorization, and oversight and audit support. Using established guidelines, this role reviews requests from physicians, pharmacies, medical groups, and members for prescription drugs and pharmacy benefits, researches and resolves issues, and collaborates closely with clinical pharmacists and other healthcare professionals to ensure accurate, compliant, and timely processing of pharmacy-related requests.

Responsibilities include:

• Review and process formulary change requests from health plans and submit updates to the pharmacy claims processor.
• Generate, maintain, and review formulary status grids to ensure accuracy and contract compliance.
• Use reports to perform audits and quality checks on current formulary status.
• Assist clinical pharmacists with formulary database maintenance and updates to the company website.
• Perform a variety of assignments related to pharmacy audit and recovery functions.
• Review paid claims for quantity and billing discrepancies and communicate findings to pharmacies.
• Send fax inquiries to pharmacies regarding audit findings and respond to faxed correspondence.
• Answer incoming calls from pharmacies and respond appropriately to questions and concerns.
• Update databases, including Access, with information from phone calls, faxes, and emails.
• Take member inquiry calls regarding pharmacy benefits, including prior authorization requests.
• Maintain expert knowledge of Medicare pharmacy benefits and formularies, including relevant regulations.
• Educate members on their specific pharmacy benefits and explain options such as prior authorization requests.
• Process member-submitted pharmacy claims accurately and efficiently.
• Review requests from physicians and pharmacies for non-formulary drugs, drugs requiring prior authorization, and prescriptions that exceed quantity or cost limits.
• Assign, enter, and document prior authorizations into the appropriate claims processing system.
• Answer phone calls related to prior authorization inquiries and provide clear information.
• Research and resolve issues using appropriate reference materials and tools.
• Understand and interpret pharmacy and medical benefits to support accurate decision-making.
• Review and process Medicare Part D event (PDE) files.
• Assist with pharmacy claims correction projects and perform audits and quality checks on active prior authorization claims.
• Help identify and correct eligibility and group issues and process member claims as needed.
• Serve as a liaison to internal and external departments for state health program pharmacy operations.
• Resolve operational issues related to prior authorization, appeals and grievances, and member or provider services.
• Prepare and review various operational reports and audits for state health programs.
• Perform formulary management functions for state health programs, including quarterly formulary updates to the website, databases, and benefit maintenance.
• Maintain prior authorization database files and process Medi-Cal direct member reimbursement (DMR) requests.
• Assist with state health program clinical projects and Medi-Cal prior authorizations.
• Assist in the implementation of regulatory changes affecting pharmacy operations.
• Participate in developing, implementing, communicating, and training on new or updated policies and procedures.
• Collaborate with business units and departments to ensure end-to-end process connectivity and effective handoffs across multiple departments.
• Provide support and monitoring to help ensure compliance of first tier, downstream, and related entities.
• Assist with department preparation for internal and external audits, including building case files, universes, and evidence of compliance.
• Identify the validity of appeals and route non-valid appeals to the appropriate department.
• Verify drug, dosage, quantity, provider, and diagnosis information for appeals.
• Research formularies and prior authorization criteria to determine if additional information is required.
• Contact providers and members to obtain additional information and clearly communicate what is needed for appeals.
• Perform other appeal-related tasks as assigned.
• Track and triage coverage determination and prior authorization requests for Medicare Part D and Part B to determine if pharmacist review is required.
• Obtain verbal authorizations and request detailed clinical information from prescribers.
• Approve coverage determinations and prior authorization requests based on defined criteria.
• Enter and document coverage determination and prior authorization decisions in the pharmacy benefit management (PBM) system and notify providers and members.
• Respond to client inquiries regarding authorization approvals and PBM online processes.
• Refer coverage determination requests for specialty drugs to delegated vendors or clients for processing.
• Contact providers for additional information to support coverage determination reviews.
• Notify physicians, providers, and members of coverage determination decisions.
• Perform other duties as assigned while adhering to all company policies and standards.

Essential Skills include:

• High school diploma or GED.
• At least 1 year of experience as a Pharmacy Technician.
• Experience with pharmacy operations such as formulary management, prior authorization, or claims processing.
• Strong data entry skills and attention to detail.
• Ability to review and process prescription drug and pharmacy benefit requests using established guidelines.
• Ability to research and resolve pharmacy-related questions, problems, and issues.
• Effective verbal and written communication skills for interacting with members, providers, and pharmacies.
• Ability to interpret pharmacy and medical benefits and apply criteria consistently.
• Proficiency in handling phone inquiries from members, providers, and pharmacies.
• Organizational skills to manage multiple tasks such as audits, reports, and database updates.
• Ability to work with clinical pharmacists and other healthcare professionals to resolve complex issues.

Additional Skills & Qualifications include:

• Customer service or retail experience preferred.
• Valid Pharmacy Technician license preferred.
• Experience with appeals and prior authorization processes.
• Familiarity with Medicare Part D and Part B pharmacy benefits and related regulations.
• Experience with state health programs, including Medi-Cal, is beneficial.
• Comfort working with databases, including updating and maintaining records.
• Ability to support regulatory implementation and audit preparation.
• Experience working with pharmacy benefit management (PBM) systems is an advantage.

Work Environment:

The Pharmacy Technician works in a structured, professional office or pharmacy operations environment that supports multiple functions such as formulary management, prior authorization, appeals, Medicare Part D operations, and state health program pharmacy operations. The role involves extensive computer and database use, including claims processing systems, PBM platforms, and tools such as Access databases, as well as frequent phone and fax communication with members, providers, pharmacies, and internal departments. The position typically follows standard business hours, with periods of higher volume during regulatory changes, audits, or peak claim cycles, requiring focus, accuracy, and adherence to established policies and procedures.

Job Type & Location:

This is a Contract to Hire position based out of Atlanta, GA.

Pay and Benefits:

The pay range for this position is $18.00 - $20.00/hr. Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type:

This is a fully remote position.

Application Deadline:

This position is anticipated to close on Sep 23, 2026.