UM Pharmacy Technician (Work from Home) New California, United States

NeueHealth, Inc.; Pennsylvania; Remote; USD 40,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated UM Pharmacy Technician to enhance the efficiency of pharmacy benefits. This role is pivotal in processing prior authorization requests, ensuring compliance with clinical guidelines, and collaborating with healthcare providers to optimize medication therapy. You will play a crucial role in minimizing unnecessary expenses and improving patient outcomes by assessing drug utilization and adhering to regulatory standards. If you have a passion for transforming healthcare and possess strong analytical and communication skills, this opportunity is perfect for you.

Qualifications

• 1-3 years of experience in pharmacy utilization management or clinical pharmacy practice.
• Understanding of CMS regulations and Medicaid/Medicare drug coverage policies.

Responsibilities

• Evaluate prior authorization requests and provide evidence-based recommendations.
• Collaborate with healthcare providers to gather clinical information.

Skills

Analytical Skills

Problem-Solving Skills

Communication Skills

Education

High School Diploma or Equivalent

Tools

Electronic Health Records (EHRs)

Prior Authorization Systems

Microsoft Office

Job description

We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.

We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

Job Summary:
The UM Pharmacy Technician is responsible for processing prior authorization requests to ensure pharmacy benefits are used efficiently, aligning with clinical guidelines, regulatory standards, and cost-containment strategies. This role involves collaboration with healthcare providers, pharmacy benefit managers (PBMs), and internal teams to optimize medication therapy, minimize unnecessary expenses, and enhance patient outcomes.

Key Responsibilities:

• Evaluate prior authorization (PA) requests and provide recommendations based on evidence-based criteria.
• Communicate with healthcare providers to gather required clinical information.
• Document review outcomes in electronic records and notify members and providers of approvals or denials as per department procedures.
• Identify and flag potential medication overuse or inappropriate medication orders.

Clinical Evaluation & Compliance:

• Assess drug utilization for safety, efficacy, and cost-effectiveness.
• Ensure adherence to state and federal regulations, including Medicare, Medicaid, and health plan payer guidelines.
• Monitor for potential fraud, waste, and abuse in medication use.

Provider & Member Support:

• Collaborate with prescribers to suggest alternative, cost-effective therapies when appropriate.
• Educate providers on formulary options, step therapy protocols, and best prescribing practices.
• Work closely with PBMs, case managers, and medical management teams to support integrated patient care.
• Contribute to quality improvement initiatives related to pharmacy utilization management.

Qualifications & Skills:

• Education: High school diploma or equivalent required
• Experience:
  • 1-3 years of experience in pharmacy utilization management, managed care, or clinical pharmacy practice.
  • Experience with prior authorization reviews, health plan pharmacy services, and PBMs.
• Understanding of CMS regulations, Medicaid/Medicare drug coverage policies, and NCQA/URAC accreditation standards.
• Proficiency in electronic health records (EHRs), prior authorization systems, and Microsoft Office applications.
• Strong analytical, problem-solving, and communication skills.