Pharmacy Prior Authorization Pro II

University Health; San Antonio (TX); On-site; USD 27,000 - 43,000; Full time

Job summary

Community First Health Plans is seeking a Prior Authorization Specialist II in Pharmacy Services. The role involves preparing and processing prior authorization requests, verifying eligibility and benefits, and notifying providers of outcomes.

You will review utilization data to identify trends and prepare compliance reports. Requirements include a high school diploma or GED (bachelor’s preferred) and five years of pharmacy experience.

Qualifications

• High school diploma or GED required; bachelor’s preferred.
• Five years of pharmacy experience required.
• Experience in health insurance/pharmacy insurance or managed care preferred.
• Prior authorization processing experience desired.
• Knowledge of InterQual criteria and coding is preferred.

Responsibilities

• Prepares pharmacy prior authorization requests for review by nurse/pharmacist/physician reviewers.
• Completes pharmacy authorization requests and issues review outcome notifications to CFHP members and providers.
• Follows clinical criteria and plan policies to approve prior auth requests.
• Performs eligibility and benefits verification.
• Reviews medication utilization reports and identifies trends through data analytics.
• Produces reports to comply with regulatory and accreditation standards.

Skills

Customer service

Phone etiquette

Typing

Attention to detail

Microsoft Office

Internet

Education

High school diploma or GED

Bachelor's degree preferred

Tools

InterQual

DRG

ICD-10

CPT coding

Job description

Community First Health Plans is seeking a Prior Authorization Specialist II in Pharmacy Services. The role involves preparing and processing prior authorization requests, verifying eligibility and benefits, and notifying providers of outcomes.

You will review utilization data to identify trends and prepare compliance reports. Requirements include a high school diploma or GED (bachelor’s preferred) and five years of pharmacy experience.