Clinical Prior Authorization Technician (Temp to Hire)

Location: Remote (U.S only)

Position Summary 

A UM Technician II prepares complex prior authorization requests by identifying clinical guidelines for review and ensuring substantial clinical information exists to reach a clinical determination for pharmacist review. The role also triages internal phone calls from members and effectively uses problem solving skills to identify gaps and obtain relevant details to resolve client, member, pharmacy personnel, and provider concerns. The role also assists leadership with departmental projects.  

Position Responsibilities:

• Prepare complex prior authorization requests by identifying clinical guidelines for review and ensuring substantial clinical information exists to reach a clinical determination for pharmacist review.  

• Proactively obtains clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review.   

• Effectively use problem solving skills to identify gaps and obtain relevant details to resolve client, member, pharmacy personnel, and provider concerns.   

• Review and analyze pharmacy claims data for proactive outreach and intervention.  

• Provide support for the prior authorization department by creating decision trees from clinical guidelines.  

• Triage phone calls from members, pharmacy personnel, and providers by asking applicable drug and client specific clinical questions.  

• Effectively communicate issues and resolutions to members, pharmacy staff, providers, and appropriate internal stakeholders.  

• Train and ensure call center pharmacy technicians perform proper protocol and best practices for intake of prior authorization from members and providers received by phone, fax, mail, and electronically.  

• Receive requests from call center and performs initial review for prior authorization and formulary exception requests based on established clinical and contract criteria.  

• Assist with departmental projects. 

• Follow all internal Standard Operating Procedures.    

• Support the Fraud, Waste, and Abuse program by reviewing pharmacy claims information and communicating findings to appropriate internal staff.   

Required Qualifications:

• Minimum of 1 year of experience as a UM Technician I at Capital Rx 

• State or National Certified Pharmacy Technician (CPhT) license required.  

• High school diploma or the equivalent; Associate’s or bachelor’s degree is preferred.  

• Excellent communication, writing, and organizational skills.   

• Ability to multi-task and collaborate in a team.  

• Self-motivated and detail-oriented problem solver.  

• Demonstrated project management skills. 

This range represents the low and high end of the anticipated base salary range for the NY - based position. The actual base salary will depend on several factors such as: experience, knowledge, and skills, and if the location of the job changes. 

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.