Excellus BCBS
Job Description
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 using pharmacy management drug policies and procedures. The technician accurately prepares and interprets cases for utilization management (UM) reviews and determination. In addition to being the content expert for the applications used to process these requests, the technician serves as a resource for staff regarding members’ specific contract benefits and supports related health plan functions such as member services, claims, and the referral/authorization process. The technician provides leadership and expertise in the intake area of the prior authorization process for medications processed through the pharmacy or medical benefit and in processing exception/prior authorization requests that follow standard protocols.
Summary The Pharmacy Prior Authorization Technician performs functions as permitted by law, including initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed using pharmacy management drug policies and procedures. The technician accurately prepares and interprets cases for utilization management (UM) reviews and determination. In addition to being the content expert for the applications used to process these requests, the technician serves as a resource for staff regarding members’ specific contract benefits and supports related health plan functions such as member services, claims, and the referral/authorization process. The technician provides leadership and expertise in the intake area of the prior authorization process for medications processed through the pharmacy or medical benefit and in processing exception/prior authorization requests that follow standard protocols.
Essential Accountabilities Level I
Conducts initial level medication prior‑authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Routes cases directly to the pharmacist or medical director for final determination, as directed.
Issues verbal and written member notification as required.
Reviews and interprets prescription and medical benefit coverage across all lines of business to determine the required prior authorization review type and documents relevant medication history and missing information.
Develops and implements process improvements to increase efficiency for the clinical staff.
Works with requesting providers, clinical pharmacists, and other internal staff to determine whether a case presentation meets approval criteria according to policy and coverage criteria.
Contacts pharmacies and physician offices to obtain clarification on prior authorization requests and to optimize the member experience.
Acts as a lead troubleshooter for the pharmacy help desk, customer care and claim processors.
Ensures appropriate authorization entry across all lines of business and verifies system interfaces for claim payment.
Performs system testing for upgrades and enhancements to the care management system.
Serves as a content expert for prior authorization intake and as a department subject matter expert for pharmacy and medical drug authorizations.
Serves as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems.
Triages prior authorization workflow daily, rerouting cases and monitoring work queues.
Provides phone coverage for incoming calls related to the UM process.
Supports medical and pharmacy drug pricing questions using government sites and other drug lookup tools.
Maintains thorough knowledge of health plan contracts, covers, and related procedures.
Performs unit‑specific workflow processes consistent with corporate policies and regulations.
Produces and distributes information for others, tracks and reports departmental performance against benchmarks.
Prepares and assists with handling correspondence.
Participates in interdepartmental coordination to ensure quality health care services, including Utilization Management, Quality Management, and Case Management.
Produces at minimum the team average medication prior‑authorization, exception and medical necessity reviews submitted to the plan.
Consistently demonstrates high standards of integrity and adherence to company values.
Maintains high regard for member privacy according to corporate privacy policies.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Level II (in addition to Level I Accountabilities)
Offers process improvement suggestions and participates in solutions for more complex issues/activities.
Understands decision tree logic and workflow, and can support the writing and implementation of question set formats.
Assists in onboarding junior staff and provides coaching.
Provides consistent positive audit results.
Works independently in coordinating and collaborating with members and providers, improving member and community health.
Manages complex assignments and detailed coordination between medical and pharmacy benefits.
Displays leadership and serves as a positive role model to others.
Produces at minimum above team average medication prior‑authorization, exception and medical necessity reviews submitted to the plan.
Level III (in addition to Level II Accountabilities)
Ensures regulatory requirements such as DOH, CMS and Medicaid are met or exceeded.
Serves as internal auditor to report issues and suggest improvements.
Process management and documentation:
Identifies, recommends and assesses new processes to improve productivity and efficiency.
Assists in updating departmental policies, procedures and desk‑top manuals.
Identifies and develops processes and guidelines for performance improvement opportunities.
Functions as a backup to the supervisor for testing and implementing system upgrades.
Serves as subject matter expert and works directly with operations and clinical staff to resolve issues and escalated problems.
Independently develops decision tree question set workflows and denial rationale based on policy criteria.
Owns a Desk Level Procedure (DLP) relating to medication prior‑authorization, exception and medical necessity reviews.
Produces the highest level of team medication prior‑authorization, exception and medical necessity reviews.
Assists teammates in meeting minimum average 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. Associate’s degree preferred.
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Level II (in Addition To Level I Qualifications)
Basic understanding 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.
High degree of professionalism, strong work ethic and positive attitude when working with internal and external customers.
Conscientious, efficient and accurate in prior authorization, exception and medical/Rx necessity review processing.
Continually strives to develop and refine skills necessary to respond to customers.
Strong customer service orientation and ability to interface effectively.
Capable of working independently and applying problem solving and analytical abilities.
Level III (in Addition To Level II Qualifications)
3–4 years’ experience with health plan‑based prior authorization and claims processing systems.
Demonstrated ability to work independently and guide others on complex benefit issues.
Demonstrated ability to independently perform system troubleshooting, liaise with IT, provider offices, training, and perform other complex utilization management functions at the intake level.
Demonstrated capacity and ability to mentor less experienced staff.
Physical Requirements
Ability to work prolonged periods sitting at a workstation and working on a computer.
Ability to work while sitting and/or standing at a workstation for three (3) or more hours at a time.
Typical office environment including fluorescent lighting.
Ability to work in a home office for continuous periods of time for business continuity.
Ability to travel across the health plan service regions as needed.
Ability to hear, understand and speak clearly while using a phone, with or without a headset.
Compensation Range Level I: $19.22 - $30.76 per hour Level II: $20.02 - $33.03 per hour Level III: $21.83 - $34.92 per hour
Equal Opportunity Employer 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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Summary The Pharmacy Prior Authorization Technician performs functions as permitted by law, including initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed using pharmacy management drug policies and procedures. The technician accurately prepares and interprets cases for utilization management (UM) reviews and determination. In addition to being the content expert for the applications used to process these requests, the technician serves as a resource for staff regarding members’ specific contract benefits and supports related health plan functions such as member services, claims, and the referral/authorization process. The technician provides leadership and expertise in the intake area of the prior authorization process for medications processed through the pharmacy or medical benefit and in processing exception/prior authorization requests that follow standard protocols.
Essential Accountabilities Level I
Conducts initial level medication prior‑authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Routes cases directly to the pharmacist or medical director for final determination, as directed.
Issues verbal and written member notification as required.
Reviews and interprets prescription and medical benefit coverage across all lines of business to determine the required prior authorization review type and documents relevant medication history and missing information.
Develops and implements process improvements to increase efficiency for the clinical staff.
Works with requesting providers, clinical pharmacists, and other internal staff to determine whether a case presentation meets approval criteria according to policy and coverage criteria.
Contacts pharmacies and physician offices to obtain clarification on prior authorization requests and to optimize the member experience.
Acts as a lead troubleshooter for the pharmacy help desk, customer care and claim processors.
Ensures appropriate authorization entry across all lines of business and verifies system interfaces for claim payment.
Performs system testing for upgrades and enhancements to the care management system.
Serves as a content expert for prior authorization intake and as a department subject matter expert for pharmacy and medical drug authorizations.
Serves as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems.
Triages prior authorization workflow daily, rerouting cases and monitoring work queues.
Provides phone coverage for incoming calls related to the UM process.
Supports medical and pharmacy drug pricing questions using government sites and other drug lookup tools.
Maintains thorough knowledge of health plan contracts, covers, and related procedures.
Performs unit‑specific workflow processes consistent with corporate policies and regulations.
Produces and distributes information for others, tracks and reports departmental performance against benchmarks.
Prepares and assists with handling correspondence.
Participates in interdepartmental coordination to ensure quality health care services, including Utilization Management, Quality Management, and Case Management.
Produces at minimum the team average medication prior‑authorization, exception and medical necessity reviews submitted to the plan.
Consistently demonstrates high standards of integrity and adherence to company values.
Maintains high regard for member privacy according to corporate privacy policies.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Level II (in addition to Level I Accountabilities)
Offers process improvement suggestions and participates in solutions for more complex issues/activities.
Understands decision tree logic and workflow, and can support the writing and implementation of question set formats.
Assists in onboarding junior staff and provides coaching.
Provides consistent positive audit results.
Works independently in coordinating and collaborating with members and providers, improving member and community health.
Manages complex assignments and detailed coordination between medical and pharmacy benefits.
Displays leadership and serves as a positive role model to others.
Produces at minimum above team average medication prior‑authorization, exception and medical necessity reviews submitted to the plan.
Level III (in addition to Level II Accountabilities)
Ensures regulatory requirements such as DOH, CMS and Medicaid are met or exceeded.
Serves as internal auditor to report issues and suggest improvements.
Process management and documentation:
Identifies, recommends and assesses new processes to improve productivity and efficiency.
Assists in updating departmental policies, procedures and desk‑top manuals.
Identifies and develops processes and guidelines for performance improvement opportunities.
Functions as a backup to the supervisor for testing and implementing system upgrades.
Serves as subject matter expert and works directly with operations and clinical staff to resolve issues and escalated problems.
Independently develops decision tree question set workflows and denial rationale based on policy criteria.
Owns a Desk Level Procedure (DLP) relating to medication prior‑authorization, exception and medical necessity reviews.
Produces the highest level of team medication prior‑authorization, exception and medical necessity reviews.
Assists teammates in meeting minimum average 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. Associate’s degree preferred.
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Level II (in Addition To Level I Qualifications)
Basic understanding 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.
High degree of professionalism, strong work ethic and positive attitude when working with internal and external customers.
Conscientious, efficient and accurate in prior authorization, exception and medical/Rx necessity review processing.
Continually strives to develop and refine skills necessary to respond to customers.
Strong customer service orientation and ability to interface effectively.
Capable of working independently and applying problem solving and analytical abilities.
Level III (in Addition To Level II Qualifications)
3–4 years’ experience with health plan‑based prior authorization and claims processing systems.
Demonstrated ability to work independently and guide others on complex benefit issues.
Demonstrated ability to independently perform system troubleshooting, liaise with IT, provider offices, training, and perform other complex utilization management functions at the intake level.
Demonstrated capacity and ability to mentor less experienced staff.
Physical Requirements
Ability to work prolonged periods sitting at a workstation and working on a computer.
Ability to work while sitting and/or standing at a workstation for three (3) or more hours at a time.
Typical office environment including fluorescent lighting.
Ability to work in a home office for continuous periods of time for business continuity.
Ability to travel across the health plan service regions as needed.
Ability to hear, understand and speak clearly while using a phone, with or without a headset.
Compensation Range Level I: $19.22 - $30.76 per hour Level II: $20.02 - $33.03 per hour Level III: $21.83 - $34.92 per hour
Equal Opportunity Employer 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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