Pharmacy Prior Authorization Specialist — Health Plan

University Health; San Antonio (TX); On-site; USD 45,000 - 60,000; Full time

Job summary

University Health seeks a professional to prepare and manage pharmacy prior authorization requests for review by clinical staff. You will verify eligibility and benefits, and communicate outcomes to CFHP members and providers, following established criteria and plan policies.

The role involves data analysis of utilization reports, identifying trends, and producing compliance reports to meet regulatory standards.

Qualifications

• High school diploma or GED required; bachelor’s degree preferred.
• Five years of pharmacy experience required; some college coursework preferred.
• Strong customer service, phone etiquette, attention to detail and typing skills.
• Basic knowledge of Microsoft Office; health insurance/pharmacy experience preferred.
• Prior authorization processing experience desired; InterQual, DRG, ICD-10, CPT knowledge preferred.

Responsibilities

• Prepares pharmacy prior authorization requests for review by nurses, pharmacists and physicians.
• Completes authorization requests and notifies CFHP members and providers of outcomes.
• Follows criteria to approve prior authorizations based on plan policies.
• Performs non-medical research including eligibility and benefits verification.
• Reviews utilization reports and identifies trends via data analytics.
• Produces reports to comply with regulatory and accreditation standards.

Education

High school diploma or GED required

Bachelor’s degree preferred

Five years of pharmacy experience required

Some college coursework preferred

Texas State Board of Pharmacy registration required

Pharmacy Technician (CPhT) certification required

Job description

University Health seeks a professional to prepare and manage pharmacy prior authorization requests for review by clinical staff. You will verify eligibility and benefits, and communicate outcomes to CFHP members and providers, following established criteria and plan policies.

The role involves data analysis of utilization reports, identifying trends, and producing compliance reports to meet regulatory standards.