Prior Authorization Technician

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.