Senior Pharmacy Technician, Utilization Management

AffirmedRx, a Public Benefit Corporation; Louisville (KY); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Competitive compensation

Health, dental, vision benefits

Job summary

AffirmedRx, a Public Benefit Corporation, is seeking a Senior Pharmacy Technician, Utilization Management, to lead non-clinical UM operations and serve as a subject matter expert for technicians. The role coordinates workflows, trains staff, and ensures compliant, timely authorization processes while protecting PHI and supporting regulatory activities.

The position requires a Bachelor's degree in a related field, 5+ years in pharmacy tech roles with UM experience, and active CPhT credentials.

Qualifications

• Bachelor's degree in a related field as listed in the job post.
• 5+ years pharmacy technician experience, with at least 3 years in UM or related operations.
• Active pharmacy technician registration and CPhT credential.
• Experience leading workflows and supervising others in a UM environment.

Responsibilities

• Receive and conduct non-clinical review of prior authorization requests.
• Verify eligibility, benefits, and authorization requirements; maintain records.
• Lead day-to-day UM operations and act as subject matter expert for technicians.
• Coordinate workflows, provide training, and escalate clinical questions to a pharmacist.
• Lead implementation and optimization of prior authorization technology and processes.
• Support audits, accreditation activities, and compliance initiatives.
• Travel 10-20% as needed.

Skills

Analytical skills

Organizational skills

Communication skills

Customer service

Problem solving

Education

Bachelor's degree in Healthcare Administration/Business Administration/Pharmacy/Health Sciences

Tools

Microsoft Office

UM systems

Job description

Position Summary:

Senior Pharmacy Technician, Utilization Management leads the non-clinical administration of pharmacy utilization management (UM) programs by receiving, processing, and conducting non-clinical review of prior authorization requests, in accordance with established workflows, coverage criteria, and regulatory requirements, and escalating non-standard or ambiguous situations to a pharmacist. The role obtains required clinical and administrative information and serves as a liaison among providers, pharmacies, members, and internal departments to support accurate, efficient, and timely authorization processes. This position does not make clinical coverage determinations requiring pharmacist licensure; however, the role exercises discretion and independent judgment on non-clinical operational, workflow, and quality matters within UM, such as work prioritization, process gaps, and workflow improvements. In addition to performing pharmacy technician responsibilities, the Senior Pharmacy Technician serves as a subject matter expert and owner of day-to-day UM operations for the UM team. The role leads workflow coordination, training and quality oversight, and the resolution of non-clinical escalations, and serves as a super-user for UM technology.

What you will do:

Utilization Management Operations:

• Receive, process, and conduct non-clinical review of pharmacy prior authorization requests and supporting documentation
• Verify member eligibility, benefit coverage, authorization requirements, and applicable administrative information
• Enter, update, and maintain authorization records within UM, pharmacy claims, and related systems
• Obtain and document required information from providers, pharmacies, members, and other health care entities
• Assess incoming prior authorization submissions for completeness and route them to the appropriate level of review, escalating to a pharmacist when standard criteria, business rules, or established workflows do not clearly apply
• Prepare cases for pharmacist review and elevate requests requiring clinical judgment or a coverage determination in accordance with established workflows
• Communicate authorization status, requests for additional information, and other non-clinical case information to providers, pharmacies, and members, as appropriate
• Maintain accurate and complete documentation of case activities, communications, and outcomes
• Monitor assigned work queues and prioritize requests to support compliance with applicable turnaround-time and notification requirements
• Support appeals, reconsiderations, audits, quality initiatives, and regulatory or accreditation activities within the technician scope of responsibility
• Protect confidential information and comply with HIPAA and all applicable federal, state, client, contractual, and organizational requirements

Operational Support and Coordination:

• Serve as a subject matter expert for UM technicians regarding workflows, policies, procedures, benefit administration, and system functionality
• Determine and manage workload distribution, queue prioritization, and coordination of urgent or time-sensitive requests across the UM technician team
• Monitor workload, turnaround times, productivity, quality, and other operational performance indicators; analyze trends or barriers and determine and implement corrective action, reporting outcomes to UM leadership
• Conduct quality reviews, identify recurring errors or workflow gaps, and provide coaching, feedback, and training to support accuracy, consistency, and compliance
• Support onboarding, mentoring, and ongoing development of new and existing UM technicians
• Develop, maintain and operationalize technician workflows, standard operating procedures, job aids, and training materials.
• Investigate and resolve non-clinical authorization issues, workflow conflicts, and provider or pharmacy inquiries, exercising discretion to determine the appropriate resolution
• Serve as a day-to-day resource for UM technicians by providing guidance on established workflows, priorities, and non-clinical operational questions; resolve non-clinical matters and elevate clinical or coverage questions to a pharmacist and operational concerns to UM leadership
• Provide backup support for designated operational leadership functions, as assigned

Technology, Implementation, and Process Improvement:

• Serve as a super-user for the prior authorization technology platform and related UM systems
• Lead operational configuration, user acceptance testing, validation, implementation, and ongoing maintenance of prior authorization technology platforms
• Lead implementation of formulary updates, utilization management programs, system enhancements, and client-specific workflows
• Collaborate with pharmacists, UM leadership, operations, clinical configuration, claims, and technology teams to investigate and resolve workflow or system issues
• Identify opportunities to improve efficiency, accuracy, service, and the user experience; assist with development and implementation of sustainable process improvements
• Support audit preparation, accreditation readiness, corrective-action activities, and compliance initiatives

What you need:

• Bachelor's degree in Healthcare Administration, Business Administration, Pharmacy, Health Sciences, or a related field
• 5+ years of pharmacy technician experience, including at least 3 years in UM, managed care, PBM, health plan, or comparable pharmacy benefit operations
• Active pharmacy technician registration, licensure, or other credential required by the state(s) in which the employee performs services
• Current Certified Pharmacy Technician (CPhT) credential
• Prior experience in a senior technician, trainer, quality reviewer, or workflow coordinator capacity
• Experience supporting operational configuration, user acceptance testing, validation, implementation, or maintenance of prior authorization or UM technology platforms
• Experience supporting pharmacy benefit configuration, formulary changes, clinical program implementation, audits, or process-improvement initiatives
• Familiarity with NCQA, URAC, ERISA, state-specific, or other applicable utilization management and pharmacy benefit requirements
• Demonstrated experience training, mentoring, coaching, or coordinating the work of others
• Working knowledge of pharmacy prior authorization operations, pharmacy benefits, formulary management, exception processing, and appeals support
• Experience using utilization management platforms, pharmacy claims systems, and Microsoft Office applications
• Strong analytical, organizational, written and verbal communication, customer service, and problem-solving skills
• Ability to exercise judgment and discretion to resolve ambiguous or non-standard operational situations, and to recognize and elevate matters that require pharmacist review
• Demonstrated ability to exercise discretion and independent judgment in resolving operational matters of significance without prior approval
• Ability to manage multiple priorities, meet turnaround-time expectations, and maintain accuracy and attention to detail in a fast-paced environment
• Ability to work independently and collaboratively across clinical, operational, and technical teams
• Ability to maintain confidentiality and appropriately handle protected health information (PHI)
• Dedicated, private, and secure remote work environment that meets organizational requirements
• Willingness to travel 10-20%

What you get:

• To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
• To work in a culture where people thrive because when OUR team thrives, OUR business thrives
• Competitive compensation, including health, dental, vision and other benefits

Note:

AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.