REMOTE Prior Authorization Representative

$37,440 - $41,600/Yr

TEKsystems - Rochester, NY

Full-time - Entry Level

Remote - Rochester, NY

10,001+ employees

Professional, Scientific, and Technical Services

About the position

The Pharmacy Prior Authorization Technician is responsible for processing and reviewing prior authorization requests for pharmacy and medical specialty drugs. This role involves utilizing pharmacy management policies to prepare and interpret cases for utilization management reviews. The Technician serves as a resource for staff regarding member benefits and provides leadership in the prior authorization process, ensuring compliance with standard protocols.

Responsibilities

• Perform initial level processing and review of prior authorization requests for pharmacy and medical specialty drugs.
• Prepare and interpret cases for utilization management reviews and determinations.
• Act as a resource for staff regarding members' specific contract benefits and related health plan functions.
• Conduct medication prior-authorization, exception, and medical necessity reviews to determine coverage under member benefits.
• Route cases to the pharmacist/medical director for final determination as directed.
• Issue verbal and written member notifications as required.
• Review and interpret prescription and medical benefit coverage across all lines of business, including Medicare D.
• Develop and implement process improvements to increase efficiency in the review process.
• Coordinate with requesting providers, clinical pharmacists, and internal staff to determine case approval criteria.
• Contact pharmacies and physician offices to clarify prior authorization requests and optimize member experience.
• Act as a lead troubleshooter for pharmacy help desk and claims processors regarding prior authorization information.
• Ensure appropriate authorization entry across all lines of business and manual manipulation of authorization as needed.
• Perform system testing for upgrades and enhancements to the care management system.

Requirements

• Prior authorization experience is highly preferred.
• Pharmacy Technician experience is a MUST.
• Must have CPhT certification.
• High School Diploma required; Associate degree or higher education preferred.
• Strong communication skills are a MUST.
• Healthcare knowledge, medical secretary, pharmacy, and outreach experience highly preferred but not required.

Nice-to-haves

• Experience in insurance verification.
• Familiarity with medical terminology.
• Experience in call center environments.
• Knowledge of insurance eligibility and coordination of benefits.
• Experience with EMR systems.

Benefits

• Competitive pay of $18-$20/hr.
• Remote work opportunity (must reside in specified operating areas).
• Full-time hours with a Monday to Friday schedule from 8am to 5pm EST.