Pharmacy Prior Authorization Specialist I

Moda Health; Portland (OR); On-site; USD 2,934,000 - 3,301,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Pharmacy benefits

Life insurance

Disability insurance

401K matching

FSA

Employee assistance program

PTO and paid holidays

Job summary

Moda Health in Portland seeks a Pharmacy PA Processor to handle electronic prior authorizations, ensuring data is accurate for claims adjudication. This full-time on-site position requires attention to detail and strong coordination with clinical teams.

Applicants should have one year of PA or technician experience in pharmacy or health plans; a Pharmacy Technician license is required, with CPHT preferred. Excellent Word/Excel skills and ability to learn PBM systems are essential.

Qualifications

• High School diploma or equivalent; college degree preferred.
• Minimum one year of prior authorization or technician experience in pharmacy/health plan.
• State Pharmacy Technician license required; CPHT preferred but not required.
• Ability to interpret benefit contracts, clinical criteria and Moda policies.
• Proficiency with Word and Excel; learn PBM claims processing systems.

Responsibilities

• Enter PAs into multiple systems, track requests and meet timelines.
• Perform first pass assessment and initial determinations on PA requests.
• Interpret formulary coverage and triage to clinical team.
• Interpret contracts and determine actions required for PA requests.
• Resolve formulary issues for members across multiple plans.
• Monitor turnaround time and ensure NCQA timelines are met.
• Communicate PA decisions to providers, members, and internal teams.
• Assist with member appeals, grievances, and documentation.

Education

High School diploma or equivalent

College degree preferred

Pharmacy Technician license

CPhT preferred

Strong Microsoft Office skills (Word, Excel)

Tools

Microsoft Office

Job description

Moda Health in Portland seeks a Pharmacy PA Processor to handle electronic prior authorizations, ensuring data is accurate for claims adjudication. This full-time on-site position requires attention to detail and strong coordination with clinical teams.

Applicants should have one year of PA or technician experience in pharmacy or health plans; a Pharmacy Technician license is required, with CPHT preferred. Excellent Word/Excel skills and ability to learn PBM systems are essential.