Remote Pharmacy Prior-Authorization Specialist

Excellus Health Plan Inc. in; Buffalo (NY); On-site; USD 29,000 - 45,000; Full time

Job summary

Excellus Health Plan is seeking a Pharmacy Prior Authorization Technician (Finance) to support managed care pharmacy programs. Under pharmacist supervision, you will review medical necessity, process prior authorization requests, and assist with data entry and reporting.

You will handle live calls to members, physicians, and pharmacists, provide information on formulary coverage, and participate in on-call rotations.

Qualifications

• High school diploma required; two years in health-related field preferred.
• Pharmacy Technician (CPhT) certification or similar preferred.
• Strong medical terminology and diagnosis knowledge.
• Excellent communication and professionalism.
• Proficient in Microsoft Office is required.

Responsibilities

• Review medical exception requests using pharmacist-created algorithms.
• Assess clinical documentation against criteria for prior authorization.
• Data entry and monitoring member profiles for PA requests.
• Provide information to physicians and pharmacists regarding initiatives.
• Provide real-time authorization certifications for prescriptions.
• Implement formulary utilization management tools.
• Collaborate with internal/external customers to resolve pharmacy benefit issues.
• Research and resolve mail-order, specialty pharmacy, or claims in Facets system.
• Provide backup coverage for Pharmacy Benefits Team.
• Monitor PBM interfaces for eligibility, claims, formulary issues.
• Monitor production and quality improvement; establish productivity/quality standards.
• Attend staff meetings and trainings.
• Perform rotating on-call responsibilities and evening shifts.
• Work additional hours to meet turnaround time.

Skills

Verbal communication

Written communication

Customer service

Problem solving

Analytical thinking

Independence

Education

High school diploma

Associate degree preferred

Pharmacy Technician (CPhT) certification preferred

LPN or Medical Assistant background preferred

Tools

Microsoft Office

Job description

Excellus Health Plan is seeking a Pharmacy Prior Authorization Technician (Finance) to support managed care pharmacy programs. Under pharmacist supervision, you will review medical necessity, process prior authorization requests, and assist with data entry and reporting.

You will handle live calls to members, physicians, and pharmacists, provide information on formulary coverage, and participate in on-call rotations.