Prior Authorization Technician I

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.

" 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.

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
Requires moving around office and non-office locations
Requires frequently moving about inside the office to access printer, files, and other materials/equipment
Operates a computer and other office equipment
Requires ability to Lift/Carry/Push/Pull - Typically less than 10 pounds

Required

• 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
• TYPING SPEED (35 WPM)
• PBM EXPERIENCE
• MANAGED CARE EXPERIENCE
• HOSPITAL PHARMACY EXPERIENCE
• LTC PHARMACY EXPERIENCE
• HOME INFUSION PHARMACY EXPERIENCE
• RETAIL PHARMACY EXPERIENCE