Pharmacy Prior Authorization Specialist

Aditi Consulting; City of Rochester (NY); On-site; USD 22,000 - 26,000; Full time

Job summary

Aditi Consulting is seeking a Pharmacy Prior Authorization Technician to perform initial level processing and reviews of prior authorization requests for pharmacy and medical specialty drug reviews. The role acts as a content expert for applications used to process requests and serves as a resource regarding member contracts and plan benefits.

Responsibilities include conducting reviews, routing cases for final determination, notifying members, and ensuring accurate auth entry across all lines

Qualifications

• High school diploma with a minimum of two years' experience in health-related field is required.
• Associates degree preferred.
• Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.

Responsibilities

• Conducts an initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member's benefit.
• Routes cases directly to the pharmacist/medical director for final determination, as directed.
• Issues verbal and written member notification as required.
• Reviews and interprets prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of prior authorization review is required.
• Develop and implement process improvement to increase efficiency in the review process for the clinical staff.
• Works with requesting providers, clinical pharmacists, and other internal staff in determining whether case presentation meets the criteria for approval.
• Triages prior authorization workflow daily by rerouting cases, alerting clinical staff of time frame deadlines, monitoring work queues.
• Provides phone coverage for incoming calls as required to support the UM process.
• Maintains knowledge of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage.

Education

High school diploma

Associates degree

Pharmacy Technician certification (CPhT)

Job description

Aditi Consulting is seeking a Pharmacy Prior Authorization Technician to perform initial level processing and reviews of prior authorization requests for pharmacy and medical specialty drug reviews. The role acts as a content expert for applications used to process requests and serves as a resource regarding member contracts and plan benefits.

Responsibilities include conducting reviews, routing cases for final determination, notifying members, and ensuring accurate auth entry across all lines