Prior Auth Pharmacy Technician - 260268

Medix Staffing Solutions, Inc.; United States; Remote; USD 28,000 - 39,000; Full time

Job summary

Medix Staffing Solutions, Inc. is seeking a Pharmacy Technician for a remote payer-side prior authorization review role. You will adjudicate PA requests by applying formulary criteria and clinical guidelines to determine coverage.

The position requires an active, unrestricted Pharmacy Technician License and the ability to navigate CMS, Medicaid, and commercial turnaround standards while maintaining high accuracy in a fast-paced, high-volume environment.

Qualifications

• Must have direct payer-side prior authorization review/adjudication experience.
• Ability to read, interpret, and apply clinical criteria and formulary guidelines.
• Demonstrated ability to read and apply utilization management rules.
• High-volume data entry accuracy with strong communication for providers.
• Ability to work under strict deadlines in a compliance-driven environment.

Responsibilities

• Payer-Side Coverage Review & Adjudication: apply criteria and rules to determine eligibility.
• Provider & Member Coordination: liaise with prescribers, pharmacies, and members to gather notes and communicate outcomes.
• Audit-Ready Documentation: maintain thorough records in internal claims/case management systems.
• Support Appeals & Reconsiderations: assist with reconsiderations and appeals workflows.
• Strict Regulatory Compliance: adhere to CMS, state Medicaid, and turnaround time standards.

Skills

PA adjudication

High-volume data entry

Communication skills

Regulatory compliance

Education

Active Pharmacy Technician license

Job description

Location: Remote

Training Schedule: Monday – Friday | 10:00 AM – 7:00 PM CST

Working Shifts: Monday - Friday (operating hours are 8am-8pm CST, work schedule will be arranged with employee after training)

***** (Please note: We are seeking candidates with experience adjudicating/reviewing prior authorizations on behalf of a health plan or PBM, rather than candidates whose experience is limited solely to submitting PA paperwork from a retail or clinic setting.)

Requirements

• Must have direct payer-side prior authorization review/adjudication experience within a PBM, Health Plan, Managed Care Organization (MCO), or PBM-adjacent clinical review environment.
• Active, unrestricted Pharmacy Technician License in your state of residence.
• Demonstrated ability to read, interpret, and apply clinical criteria, medical charts, and formulary guidelines to determine medication coverage.
• Deep understanding of utilization management principles (prior authorization, step therapy, quantity limits, and tiered formularies).
• High-volume data entry accuracy and strong written/verbal communication skills for provider outreach.
• Ability to thrive under strict deadlines and compliance-driven production benchmarks.

Key Responsibilities

• Payer-Side Coverage Review & Adjudication: Review incoming prior authorization requests and render eligibility determinations by applying plan formulary criteria, clinical guidelines, step therapy, and utilization management rules.
• Provider & Member Coordination: Liaise telephonically with prescriber offices, pharmacies, and members to gather necessary clinical chart notes, clarify diagnostic information, and communicate determination outcomes.
• Audit-Ready Documentation: Maintain thorough, accurate records of all PA submissions, approvals, denials, renewals, and outreach notes in internal claims/case management platforms.
• Support Appeals & Reconsiderations: Assist clinical pharmacists and medical directors with reconsiderations, redeterminations, and appeals workflows, ensuring continuous operational alignment.
• Strict Regulatory Compliance: Adhere strictly to CMS, state Medicaid, and commercial turnaround time (TAT) standards while maintaining high accuracy and efficiency in high-volume queues.