Prior Authorization Technician I

Ohm Systems; Philadelphia (Philadelphia County); Remote; USD 25,000 - 39,000; Full time

Job summary

Ohm Systems is seeking a Prior Authorization Technician I for a remote role with EST hours. You will review and process PA requests, communicating with providers and members to obtain necessary information, and submitting authorizations to claims systems.

The ideal candidate has 1–3 years in pharmacy settings, PTCB/NHA certification, and knowledge of PBM processes. This position supports multiple time zones and requires a reliable home setup.

Qualifications

• High school diploma or GED required.
• PTCB or NHA certification; licensure as required by state.
• 1–3 years in related pharmacy setting preferred.
• Experience with prior authorization procedures advantageous.

Responsibilities

• Review and process prior authorization requests per criteria.
• Interface with providers, members, and pharmacies to gather information.
• Submit authorizations to pharmacy and medical claims systems.
• Escalate to a pharmacist when needed.
• Handle inbound inquiries from customer care about prior authorizations.
• Maintain productivity and quality in a fast-paced environment.
• Attend required trainings and adhere to policies.

Skills

Typing 35 wpm

Prior Authorization experience

PBM exposure

Education

High School / GED

PTCB/NHA Certification

Job description

Shift

• Position is remote. No time zone preference but shift times offered will be in EST time so candidates will need to adjust accordingly if in a different time zone.
• Shift Schedule: 8:30am-5:00pm EST, 9:00am-5:30pm EST, or 9:30am-6:00pm EST

Duties

• Reporting directly to the Supervisor, Prior Authorization Technicians, the Prior Authorization Technician I processes prior authorization requests received from providers, members, and pharmacies, including requests for high cost and specialty medications.

Essential Functions

• Interprets and applies clinical criteria during the prior authorization review process and approves requests if applicable
• Utilizes member claims history during the prior authorization review process
• Makes outbound calls to obtain additional information needed to process prior authorization requests
• Submits authorizations to pharmacy and medical claims processors
• Forwards prior authorization requests to a pharmacist when necessary
• Makes appropriate referrals to other clinical programs
• Assists in directing appropriate requests to in network providers
• Receives inbound calls from the customer care center with prior authorization related inquiries
• Assist with Appeals processing as assigned
• Ability to multitask between various tasks and systems while maintaining required productivity and quality levels
• Ability to make changes in a fast-paced environment
• Strong knowledge of specialty and non-specialty pharmaceuticals
• Performs other job-related duties and projects as assigned
• Attends required training on an annual basis.
• Adheres to corporate and departmental policies and procedures.
• Available to work weekends and holidays

Skills

• 1 to 3 Years required.
• Previous PBM, managed care, hospital pharmacy, LTC pharmacy, Home Infusion pharmacy, retail pharmacy experience preferred.
• Minimum 35 words per minute typing speed.

Education

• High School/GED Required
• Certified Pharmacy Technician (PTCB or NHA). May be required to be licensed or certified in a specific state based upon contractual requirements and business need.
• Requires working shift schedule outside standard business hours
• Must remain in stationary position for long periods of time at desk or computer
• Requires moving around office and non-office locations
• Requires frequently moving about inside the office to access printer, files, and other materials/equipment
• Operates a computer and other office equipment
• Requires ability to Lift/Carry/Push/Pull - Typically less than 10 pounds