Pharmacy Prior Authorization Technician I
hace 6 días
Aurora
Job Description The Prior Authorization Technician is responsible for the accurate and timely review, documentation, and system entry of prescription prior authorization (PA) requests. This role involves managing inbound and outbound calls with providers, members, and pharmacies to ensure criteria-based processes are completed thoroughly. Additional responsibilities include conducting outreach calls, monitoring and responding to mailbox inquiries, reviewing daily rejection reports, and providing internal and external support to ensure accurate medication claim processing. The technician is also responsible for maintaining complete and timely documentation of PA criteria within the system, assisting with clinical programs as needed, and performing other duties as assigned by leadership. To support team coverage, the Prior Authorization Technician will participate in a holiday rotation schedule. ESSENTIAL JOB FUNCTIONS AND DUTIES • Understands prescription drug benefits, including adjudication and NCPDP reject codes, • Reviews and processes prior authorization requests from providers via phone, fax, email, or mail, • Conducts outreach to providers and members for clinical documentation, • Communicates formulary guidelines, alternatives, and benefit criteria to members, providers, and pharmacies, • Resolves claim issues (e.g., refill-too-soon, pricing errors, max dose, DUR) and escalated member concerns, • Maintains knowledge of plan-specific benefit designs, copays, and pharmacy networks, • Updates and manages prior authorization criteria in PA systems (e.g., PA Hub/Agadia), • Performs data analysis in Excel to support reporting and communications (e.g., mail merges), • Communicates plan changes through calls, faxes, and mailings, • Supports clinical programs through outreach, data tracking, and claims monitoring, • Assists with department projects and continuous improvement initiatives, • Contributes to team goals (e.g., service level, call metrics, unresolved faxes), • Provides excellent customer service and escalates member issues appropriately, • Supports member access to manufacturer assistance programs, • Demonstrates professionalism and promotes a respectful, inclusive work environment, • Performs additional duties as assigned and essential functions with or without reasonable accommodation ESSENTIAL QUALIFICATIONS Required Experience and Skills • 2–4 years of experience as a pharmacy technician, • 2–4 years of experience in prior authorization within a pharmacy benefit managed care environment (e.g., PA Hub–Agadia), • 2–4 years of experience with third-party rejects and claims resolution, • 2–4 years of experience with medical/prescription payment and claims adjudication systems (e.g., RxClaims) Preferred Experience and Skills • 2–4 years of customer service experience with patients, providers, and pharmacies, • Intermediate proficiency in Microsoft Office Suite, including Excel (VLOOKUP, SUM, AVERAGE, Sort, Filter, Table creation), Outlook, PowerPoint, and Word Education, Licenses, and Certifications • High School diploma or GED, • Required: Certified Pharmacy Technician (CPhT) License Salary range for this position: Hourly: $25.69 - $31.44. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location. Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) as a remote employee. We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Short- & Long-term Disability, Pension, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).