Prior Authorization Specialist Pharmacy Services CFHP

University Health; San Antonio (TX); Sur place; USD 45 000 - 60 000; Plein temps

Résumé du poste

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.

Responsabilités

• 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.

Formation

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

Description du poste

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.