Prior Authorization Technician

Duties

• The Prior Authorization Technician I assists in the prior authorization process.
• Reports directly to the Supervisor, Prior Authorization Technicians.
• Processes prior authorization requests received from providers, members, and pharmacies, including requests for high-cost and specialty medications.
• 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
• Previous PBM, managed care, hospital pharmacy, LTC pharmacy, Home Infusion pharmacy, and retail pharmacy experience preferred.
• Minimum 35 words per minute typing speed.

Education

• High School/GED
• Certified Pharmacy Technician (PTCB or NHA) Required