Prior Authorization Technician I

Techlink Systems Inc.; Philadelphia (Philadelphia County); Remote; USD 42,000 - 62,000; Full time

Job summary

Techlink Systems Inc. seeks a Prior Authorization Technician I to process requests from providers, members, and pharmacies, including high-cost and specialty medications. You will interpret criteria, use claims history, and make outbound calls to gather information.

This remote role offers EST shift times and requires High School/GED and a PTCB/NHA certification, with occasional weekend availability and ability to multitask.

Qualifications

• High School/GED required; professional certification preferred.
• PTCB or NHA certification; licensure may be required by contract.
• Shift schedule outside standard business hours required.
• Must remain in stationary position at desk/computer for long periods.
• Requires occasional moving around office and lifting up to 10 pounds.

Responsibilities

• Interprets and applies clinical criteria during prior authorization reviews and approves requests when applicable.
• Uses member claims history during the prior authorization review process.
• Makes outbound calls to obtain additional information needed to process requests.
• Submits authorizations to pharmacy and medical claims processors.
• Forwards requests to pharmacists when necessary and directs to in-network providers.
• Receives inbound calls related to prior authorization inquiries and assists in Appeals processing.

Skills

Prior Authorization Processing

Clinical Criteria Interpretation

Member Claims History Utilization

Outbound Calling

Authorization Submission

Typing 35 WPM

PBM Experience

Education

High School/GED

Certified Pharmacy Technician (PTCB or NHA)

Job description

Job Title: Prior Authorization Technician I
Location (On-site, Remote, or Hybrid?): 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.
Contract Duration: Contract until 01/15/2027
Work Hours: 8:30am-5:00pm EST, 9:00am-5:30pm EST, or 9:30am-6:00pm EST

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

Skills:
Required

• Prior Authorization Processing
• Clinical Criteria Interpretation
• Member Claims History Utilization
• Outbound Calling
• Authorization Submission

Additional

• Adaptability
• Referral Management
• Appeals Processing
• Multitasking
• Specialty Pharmaceuticals Knowledge
• Non-Specialty Pharmaceuticals Knowledge
• Typing Speed (35 Wpm)
• PBM Experience
• Managed Care Experience
• Hospital Pharmacy Experience
• LTC Pharmacy Experience
• Home Infusion Pharmacy Experience
• Retail Pharmacy Experience