Prior Authorization Specialist II Pharmacy Services CFHP

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

Prior Authorization Specialist II Pharmacy Services CFHP

Community First Health Plans

TPA DCHP PHM POPULATION HEALTH MGM

Full Time

Day Shift

Salary Range: $19.80 - $31.25

POSITION SUMMARY/RESPONSIBILITIES

Prepares pharmacy prior authorization requests for review by nurse/pharmacist/physician reviewers. Completes pharmacy authorization requests and issues review outcome notifications to Community First Health Plans (CFHP) members and providers. Follows clinical criteria and instructions to approve prior authorization requests based on established criteria, plan policies and procedures. Performs non-medical research including eligibility verification and benefits verification. Reviews medication utilization reports and identifies trends through advanced data analytics. Produces reports to comply with regulatory and accreditation standards

EDUCATION/EXPERIENCE

Graduation from high school/GED required. Bachelor’s degree preferred. Five years of pharmacy experience required. Some coursework at the college level is preferred. Excellent customer service, phone etiquette, attention to detail, and typing skills is required. Basic knowledge of Microsoft Office and internet required. Experience in health insurance/pharmacy insurance or managed care organization preferred. Prior authorization processing experience desired. Experience in a PBM or managed care call center desired. Knowledge of InterQual screening criteria as well as DRG, ICD-10 and CPT coding is preferred.

LICENSURE/CERTIFICATION

Texas State Board of Pharmacy registration required. Certification as a Pharmacy Technician (CPhT) is required.