Note ::

• Remote Role no time zone preference but candidates will be assigned a shift time that supports our business needs which are EST time. Shift times are discussed in detail during interviews.
• Not required state license for this posting. The national certifications (PTCB or NHA) will suffice.

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 experience
• Previous PBM, managed care, hospital pharmacy, LTC pharmacy, Home Infusion pharmacy, retail pharmacy experience preferred.
• Minimum 35 words per minute typing speed.

Education:

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