The Prior Authorization Specialist is responsible for reviewing prior authorization requirements with a Clinical Innovation Pharmacist and addressing PA questions from members, providers (prescribers), pharmacy personnel, and Health Plans.
- Provide support for Clinical Programs to create and maintain prior authorization guidelines for clinical product offerings.
- Gather all required information for the PA review.
- Intake Prior Authorization requests from the phone and fax queue.
- Review and approve physician inquiries for pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.
- Conducts root-cause analysis for any issues associated with a PA request.
- Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, financial, and operational effectiveness and quality.
- Provides support for internal and external audits and surveys.
- Maintain accurate and complete documentation of all inquiries for continuous improvement.
- Follow all internal Policies & Procedures to ensure consistency, accuracy, and operational effectiveness.
- Supports Fraud, Waste and Abuse program system oversight and communicates any suspected fraud discovered.
- Follows all state and federal regulations applicable to PBM operations and utilization management.
- Maintains quality service by enforcing quality and stakeholder service standards, analyzing, and resolving quality and stakeholder (member, client, pharmacy) service problems and recommending system improvements.
- High school diploma or the equivalent required. Associate’s or bachelor’s degree is preferred
- 2 – 5 years of pharmacy technician experience in a retail pharmacy, PBM, hospital, clinical pharmacy, or long-term care environment
- PTCB or equivalent certification required
- Active Pharmacy Technician license (multiple states may be required)
- Strong PC skills; MS Word, Excel, Access, and Power Point.
Applicants must be able to pass a background investigation as all offers are pending a successful completion of background check per the company policy.