This position supports the network centralized prior authorization department. Coordinates and administers the effective and efficient processing of the pharmacy benefits prior authorization process, ensuring that pharmacy benefits are administered in accordance with all regulatory agency requirements. Reviews pharmacy utilization management (UM) coverage requests and prepares such cases for clinical review by a pharmacist and/or medical director when required. Applies plan-specific benefits to each case appropriately, summarizes pertinent facts, and cites applicable internal policies and guidelines. Resolves non-clinical issues independently and acts as a liaison between our customer and provider-facing teams and the Corporate Pharmacy Department. Maintains regulatory compliance and resolves all cases within predetermined timeframes. Responsible for all preauthorization entries into applicable databases to ensure swift and appropriate payment of services deemed medically necessary. Engages in member and provider outreach to resolve non-clinical issues such as appeal initiation requests, processing errors, and fulfilling notification requirements among others. May perform other non-clinical duties as required by management and department needs. Requires 2 years of experience as a Pharmacy Technician in a hospital, retail, or managed care setting and Certified Pharmacy Technician (CPhT) from Pharmacy Technician Certification Board. Associate degree preferred. Travel requirement 0% - 25%. Compliance with HIPAA and company policies required.
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