Excellus BCBS
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Job Overview The Pharmacy Prior Authorization Technician performs functions as permitted by law, including the initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed utilizing pharmacy management drug policies and procedures. The position accurately prepares and interprets cases for UM (utilization management) reviews and determinations. The technician is the content expert for the applications used to process these requests and serves as a resource for staff regarding members’ specific contract benefits. Consistent with products, policies, and procedures the technician provides expertise in member services, claims, referral/authorization processes, and leadership in the intake area of the prior authorization process for medications processed through pharmacy or medical benefit, including exception and prior authorization requests that follow standard protocols.
Essential Accountabilities Level I
Conduct initial level medication prior‑authorization, exception, and medical necessity reviews submitted to the plan.
Route cases directly to pharmacists or medical directors 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, to determine the type of prior authorization review required.
Document medication history and missing information to assist pharmacists, nurses, and physicians in the review process.
Develop and implement process improvements to increase efficiency for clinical staff.
Work with requesting providers, clinical pharmacists, and other internal staff to determine whether case presentation meets approval criteria per medical or prescription drug policy.
Contact pharmacies and physician offices to obtain clarification on prior authorization requests and drugs billed through point‑of‑sale or medical claim systems.
Act as a lead troubleshooter for the pharmacy help desk, customer care, and claim processors to coordinate claims with prior authorization information.
Ensure appropriate authorization entry across all lines of business and that care management interfaces with claim processing systems for payment.
Perform system testing for upgrades and enhancements to the care management system.
Act as a content expert for prior authorization intake for internal and external customers.
Serve as a liaison for the prior authorization process and its interface to pharmacy and medical claim systems.
Triage prior authorization workflow daily by rerouting cases and alerting clinical staff of deadlines.
Provide phone coverage for incoming calls related to UM process, authorization inquiries, and claim inquiries.
Support medical and pharmacy drug pricing questions and use drug lookup tools.
Maintain knowledge of health plan contracts, riders, policy statements, and procedures.
Perform unit‑specific workflow processes consistent with corporate policies and regulations.
Produce, record, or distribute information and track performance against benchmarks.
Assist in handling correspondence and ensure accuracy and timeliness of processing.
Participate in interdepartmental coordination to ensure delivery of high‑quality health care services.
Produce team‑average medication prior‑authorization, exception, and medical necessity reviews as required.
Demonstrate high standards of integrity and adherence to the corporate code of conduct.
Maintain member privacy in accordance with corporate privacy policies and procedures.
Maintain regular and reliable attendance.
Perform additional duties as assigned by management.
Essential Accountabilities Level II (in addition to Level I)
Offer process improvement suggestions and participate in solving complex issues.
Understand decision tree logic and workflow; support writing and implementation of the question set format.
Assist in onboarding junior staff and provide coaching as necessary.
Provide consistent positive audit results.
Coordinate with members and providers independently, improving member and community health.
Manage complex assignments and detailed coordination between medical and pharmacy benefits.
Display leadership and serve as a positive role model.
Produce above team‑average medication prior‑authorization, exception, and medical necessity reviews.
Essential Accountabilities Level III (in addition to Level II)
Ensure regulatory requirements such as DOH, CMS, and Medicaid are met or exceeded across all lines of business.
Serve as internal auditor to report issues and suggest improvements.
Identify, recommend, and assess new processes to improve productivity and gain efficiencies.
Assist in updating departmental policies and desk‑top manuals.
Act as a backup to the supervisor for testing and implementation of system upgrades.
Serve as subject matter expert and resolve escalated problems, owning a specialist title on the team.
Develop decision tree question set workflows and denial rationale independently.
Own a Desk Level Procedure (DLP) related to medication prior‑authorization, exception, and medical necessity reviews.
Produce the highest level of team medication prior‑authorization, exception, and medical necessity reviews.
Assist teammates in meeting at least the average of medication prior‑authorization reviews for their level of experience.
Minimum Qualifications All Levels:
High school diploma with a minimum of two years’ experience in a health‑related field (associates degree preferred).
Pharmacy Technician certification (CPhT), LPN, or Medical Assistant/Technologist background strongly preferred.
Level II Qualifications (in addition to Level I)
Basic understanding and interpretation of medical terminology and diagnosis codes.
Basic understanding of drug classes and therapeutic interchange.
Clear understanding of prescription and medical benefits as they apply to the utilization review process.
Proficient experience with Microsoft Office suite.
Strong verbal and written communication skills.
Professionalism, strong work ethic, and positive attitude toward internal and external customers.
Conscientious, efficient, and accurate in prior authorization, exception, and medical/Rx necessity review processing.
Continual desire to develop and refine customer‑service skills.
Strong customer‑service orientation and ability to interface effectively.
Capability to work independently with analytical problem‑solving abilities.
Level III Qualifications (in addition to Level II)
3–4 years of experience with health‑plan based prior authorization and claims processing systems.
Ability to work independently and guide others on complex benefit issues.
Experience performing system troubleshooting, liaising with IT, provider offices, training, and other complex utilization management functions at the intake level.
Capacity to mentor less experienced staff.
Physical Requirements
Ability to work prolonged periods sitting at a workstation and on a computer.
Ability to work while sitting or standing while at a workstation for 3 or more hours at a time.
Typical office environment including fluorescent lighting.
Ability to work in a home office for continuous periods for business continuity.
Ability to travel across health plan service regions as needed.
Ability to hear, understand, and speak clearly while using a phone, with or without a headset.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Compensation Range Level I: $19.22 – $30.76 Level II: $20.02 – $33.03 Level III: $21.83 – $34.92
The salary range indicates the minimum and maximum for this position. Actual salary varies based on factors including budget, experience, and qualifications. Salary ranges reflect just one component of the total rewards package, which may include group health and dental insurance, retirement plan, wellness program, paid time off, and paid holidays.
Please note: Opportunity for remote work may exist for all jobs posted by the Excellus Talent Acquisition team. This is evaluated case‑by‑case.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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Get AI-powered advice on this job and more exclusive features.
Job Overview The Pharmacy Prior Authorization Technician performs functions as permitted by law, including the initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed utilizing pharmacy management drug policies and procedures. The position accurately prepares and interprets cases for UM (utilization management) reviews and determinations. The technician is the content expert for the applications used to process these requests and serves as a resource for staff regarding members’ specific contract benefits. Consistent with products, policies, and procedures the technician provides expertise in member services, claims, referral/authorization processes, and leadership in the intake area of the prior authorization process for medications processed through pharmacy or medical benefit, including exception and prior authorization requests that follow standard protocols.
Essential Accountabilities Level I
Conduct initial level medication prior‑authorization, exception, and medical necessity reviews submitted to the plan.
Route cases directly to pharmacists or medical directors 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, to determine the type of prior authorization review required.
Document medication history and missing information to assist pharmacists, nurses, and physicians in the review process.
Develop and implement process improvements to increase efficiency for clinical staff.
Work with requesting providers, clinical pharmacists, and other internal staff to determine whether case presentation meets approval criteria per medical or prescription drug policy.
Contact pharmacies and physician offices to obtain clarification on prior authorization requests and drugs billed through point‑of‑sale or medical claim systems.
Act as a lead troubleshooter for the pharmacy help desk, customer care, and claim processors to coordinate claims with prior authorization information.
Ensure appropriate authorization entry across all lines of business and that care management interfaces with claim processing systems for payment.
Perform system testing for upgrades and enhancements to the care management system.
Act as a content expert for prior authorization intake for internal and external customers.
Serve as a liaison for the prior authorization process and its interface to pharmacy and medical claim systems.
Triage prior authorization workflow daily by rerouting cases and alerting clinical staff of deadlines.
Provide phone coverage for incoming calls related to UM process, authorization inquiries, and claim inquiries.
Support medical and pharmacy drug pricing questions and use drug lookup tools.
Maintain knowledge of health plan contracts, riders, policy statements, and procedures.
Perform unit‑specific workflow processes consistent with corporate policies and regulations.
Produce, record, or distribute information and track performance against benchmarks.
Assist in handling correspondence and ensure accuracy and timeliness of processing.
Participate in interdepartmental coordination to ensure delivery of high‑quality health care services.
Produce team‑average medication prior‑authorization, exception, and medical necessity reviews as required.
Demonstrate high standards of integrity and adherence to the corporate code of conduct.
Maintain member privacy in accordance with corporate privacy policies and procedures.
Maintain regular and reliable attendance.
Perform additional duties as assigned by management.
Essential Accountabilities Level II (in addition to Level I)
Offer process improvement suggestions and participate in solving complex issues.
Understand decision tree logic and workflow; support writing and implementation of the question set format.
Assist in onboarding junior staff and provide coaching as necessary.
Provide consistent positive audit results.
Coordinate with members and providers independently, improving member and community health.
Manage complex assignments and detailed coordination between medical and pharmacy benefits.
Display leadership and serve as a positive role model.
Produce above team‑average medication prior‑authorization, exception, and medical necessity reviews.
Essential Accountabilities Level III (in addition to Level II)
Ensure regulatory requirements such as DOH, CMS, and Medicaid are met or exceeded across all lines of business.
Serve as internal auditor to report issues and suggest improvements.
Identify, recommend, and assess new processes to improve productivity and gain efficiencies.
Assist in updating departmental policies and desk‑top manuals.
Act as a backup to the supervisor for testing and implementation of system upgrades.
Serve as subject matter expert and resolve escalated problems, owning a specialist title on the team.
Develop decision tree question set workflows and denial rationale independently.
Own a Desk Level Procedure (DLP) related to medication prior‑authorization, exception, and medical necessity reviews.
Produce the highest level of team medication prior‑authorization, exception, and medical necessity reviews.
Assist teammates in meeting at least the average of medication prior‑authorization reviews for their level of experience.
Minimum Qualifications All Levels:
High school diploma with a minimum of two years’ experience in a health‑related field (associates degree preferred).
Pharmacy Technician certification (CPhT), LPN, or Medical Assistant/Technologist background strongly preferred.
Level II Qualifications (in addition to Level I)
Basic understanding and interpretation of medical terminology and diagnosis codes.
Basic understanding of drug classes and therapeutic interchange.
Clear understanding of prescription and medical benefits as they apply to the utilization review process.
Proficient experience with Microsoft Office suite.
Strong verbal and written communication skills.
Professionalism, strong work ethic, and positive attitude toward internal and external customers.
Conscientious, efficient, and accurate in prior authorization, exception, and medical/Rx necessity review processing.
Continual desire to develop and refine customer‑service skills.
Strong customer‑service orientation and ability to interface effectively.
Capability to work independently with analytical problem‑solving abilities.
Level III Qualifications (in addition to Level II)
3–4 years of experience with health‑plan based prior authorization and claims processing systems.
Ability to work independently and guide others on complex benefit issues.
Experience performing system troubleshooting, liaising with IT, provider offices, training, and other complex utilization management functions at the intake level.
Capacity to mentor less experienced staff.
Physical Requirements
Ability to work prolonged periods sitting at a workstation and on a computer.
Ability to work while sitting or standing while at a workstation for 3 or more hours at a time.
Typical office environment including fluorescent lighting.
Ability to work in a home office for continuous periods for business continuity.
Ability to travel across health plan service regions as needed.
Ability to hear, understand, and speak clearly while using a phone, with or without a headset.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Compensation Range Level I: $19.22 – $30.76 Level II: $20.02 – $33.03 Level III: $21.83 – $34.92
The salary range indicates the minimum and maximum for this position. Actual salary varies based on factors including budget, experience, and qualifications. Salary ranges reflect just one component of the total rewards package, which may include group health and dental insurance, retirement plan, wellness program, paid time off, and paid holidays.
Please note: Opportunity for remote work may exist for all jobs posted by the Excellus Talent Acquisition team. This is evaluated case‑by‑case.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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