Remote Pharmacy Prior Authorization Specialist

Capital District Physicians Health Plan, Inc.; Buffalo (NY); On-site; USD 29,000 - 45,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Retirement plan

Wellness program

Paid time off

Paid holidays

Remote work on case-by-case basis

Job summary

Univera Healthcare is seeking a detail-oriented health plan professional to support prior authorization processes within the Pharmacy Benefits Team. The role involves reviewing medical exception requests, validating documentation, and providing real-time authorization certifications for prescription medications.

Applicants should have a high school diploma and experience in a health-related field; an associate degree is preferred.

Qualifications

• High school diploma or equivalent required.
• Associates degree preferred.

Responsibilities

• Review medical exception requests based on pharmacist-created algorithms.
• Assess clinical documentation to determine prior authorization approvals.
• Enter data and monitor member profiles for prior authorization requests and ad hoc reports.
• Provide information to physicians and pharmacists by phone regarding prescription initiatives.
• Perform real-time authorization certification for prescription medications and related requests.
• Implement formulary utilization tools (prior authorization, quantity limits, step therapy, etc.).
• Coordinate with internal/external customers to resolve system and formulary issues.
• Research mail-order services, specialty pharmacy, or formulary issues in the Facets system.
• Provide backup coverage for Pharmacy Benefits Team and assist with inquiries.
• Monitor PBM interfaces for eligibility and claims; conduct testing as needed.
• Attend staff meetings; participate in on-call duties; work extra hours to meet deadlines.
• Comply with Corporate Compliance Policy and report suspected violations.

Job description

Univera Healthcare is seeking a detail-oriented health plan professional to support prior authorization processes within the Pharmacy Benefits Team. The role involves reviewing medical exception requests, validating documentation, and providing real-time authorization certifications for prescription medications.

Applicants should have a high school diploma and experience in a health-related field; an associate degree is preferred.