Prior Authorization Technician

Summary: The Prior Authorization Technician I plays a crucial role in the prior authorization process, assisting with requests from providers, members, and pharmacies. This position requires interpreting clinical criteria, making outbound calls for additional information, and processing authorizations efficiently. The technician must also manage inquiries from the customer care center and maintain productivity in a fast-paced environment. Strong knowledge of pharmaceuticals and multitasking abilities are essential for success in this role.

Key Responsibilities:

• 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.

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

Salary (Rate): undetermined

City: undetermined

Country: USA

Working Arrangements: Remote

IR35 Status: Outside IR35

Seniority Level: undetermined

Industry: Other