Prior Authorization Technician I

TALENT Software Services; Philadelphia (Philadelphia County); On-site; USD 42,000 - 48,000; Full time

Job summary

TALENT Software Services seeks a Prior Authorization Technician I to process requests from providers, members, and pharmacies. You will interpret clinical criteria, utilize claim history, and collaborate with pharmacists when needed.

The role requires knowledge of specialty and non-specialty pharmaceuticals, with strong keyboarding skills and the ability to multitask in a fast-paced healthcare environment. Weekend/holiday availability is expected.

Qualifications

• 1–3 years in a PBM, managed care, or pharmacy role.
• Certified Pharmacy Technician with valid credential (PTCB or NHA).
• Typing speed of at least 35 words per minute.

Responsibilities

• Process prior authorization requests from providers, members, and pharmacies.
• Interpret clinical criteria and approve requests when applicable.
• Contact for additional information to complete reviews; submit authorizations.
• Forward requests to pharmacists or in-network providers as needed.
• Assist in Appeals processing and related tasks as assigned.
• Maintain productivity and quality across multiple tasks and systems.

Skills

Experience: 1-3 years

PBM/Managed care exposure

Typing 35 wpm

Education

High School Diploma or GED

PTCB or NHA Certification

State license/certification as required

Job description

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