Excellus BCBS
Pharmacy Prior Authorization Technician
Company:
Excellus BCBS
This position 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. The technician accurately prepares and interprets cases for utilization management (UM) reviews and determination. The Technician serves as a resource for staff regarding members’ specific contract benefits, consistent with products, policies and procedures and 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
Conduct initial level medication prior‑authorization, exception and medical necessity reviews to determine coverage under the member’s benefit.
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, to determine the type of prior authorization review needed, and document any missing information.
Develop and implement process improvements to increase efficiency in the review process for the clinical staff.
Work with requesting providers, clinical pharmacists, and other internal staff to determine whether a case meets the criteria for approval according to policy and coverage criteria.
Contact pharmacies and physician offices to obtain clarification on prior authorization requests and drugs billed through the point‑of‑sale system or medical claim system.
Act as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy/medical claims with prior authorization information.
Ensure proper auth entry across all lines of business; interface care management system to claim processing system for claim payment, performing manual manipulation of auth when required.
Perform system testing for upgrades and enhancements to the care management system.
Serve as the content expert for prior authorization intake and act as the department’s subject matter expert for pharmacy and medical drug authorizations.
Act as the lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems, triaging issues to the appropriate department.
Triage prior authorization workflow daily by rerouting cases, alerting clinical staff of deadlines, monitoring queues and keeping management aware of compliance‑mandated deadlines.
Provide phone coverage for incoming calls to support the UM process, including authorization inquiries, claim inquiries and other related inquiries.
Support medical and pharmacy drug pricing questions using drug lookup tools such as government sites and other online resources.
Maintain thorough knowledge of health plan contracts, riders, policy statements and procedures to identify eligibility and coverage and assist staff with related inquiries.
Perform unit‑specific workflow processes consistent with corporate policies and regulatory agencies.
Produce or distribute information for others, track and report department performance against benchmarks.
Prepare and assist in handling correspondence, ensuring accuracy and timeliness.
Participate in interdepartmental coordination and communication to ensure consistent, quality health‑care services (e.g., Utilization Management, Quality Management, Case Management).
Consistently demonstrate high standards of integrity, supporting the company’s mission, values and code of conduct.
Maintain regard for member privacy per corporate privacy policies and procedures.
Maintain regular and reliable attendance.
Perform other functions as assigned by management.
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 with onboarding of junior staff and provide coaching as necessary.
Provide consistent positive audit results.
Work independently in coordinating and collaborating with members and providers to improve member and community health.
Manage complex assignments and detailed coordination between the medical and pharmacy benefits.
Display leadership and serve as a positive role model in the department.
Produce above‑team‑average medication prior‑authorization, exception and medical necessity reviews for the plan.
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.
Process management and documentation: identify, recommend and assess new processes to improve productivity.
Assist in updating departmental policies, procedures and desktop manuals.
Serve as backup to the supervisor for testing and implementing system upgrades.
Work directly with the operation and clinical staff to resolve issues and escalated problems; hold specialist designation.
Independently develop decision‑tree question‑set workflows and denial rationale based on policy criteria.
Own a Desk‑Level Procedure (DLP) for 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 maintaining the minimum average benchmarks for their level of experience.
Minimum Qualifications
High school diploma with a minimum of two years’ experience in a health‑related field (Associates degree preferred).
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Level II: basic understanding of medical terminology and diagnosis codes; drug classes and therapeutic interchange; prescription and medical benefits as it applies to the utilization review process; proficiency in Microsoft Office; strong verbal and written communication; professionalism, work ethics and a positive attitude; accuracy in prior authorization processing; customer‑service orientation; ability to work independently and apply problem‑solving skills.
Level III: 3–4 years of experience with health plan‑based prior authorization and claims processing systems; ability to work independently, mentor less experienced staff, and perform systems troubleshooting and technical liaison.
Physical Requirements
Work prolonged periods sitting at a workstation and using a computer.
Work while sitting/standing at a workstation for at least three hours.
Typical office environment with fluorescent lighting.
Work in a home office for continuity.
Travel across service regions as needed.
Ability to hear, understand and speak clearly while using a phone.
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.
Compensation Range
Level I: $19.22–$30.76
Level II: $20.02–$33.03
Level III: $21.83–$34.92
Remote work may be available on a case‑by‑case basis.
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Excellus BCBS
This position 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. The technician accurately prepares and interprets cases for utilization management (UM) reviews and determination. The Technician serves as a resource for staff regarding members’ specific contract benefits, consistent with products, policies and procedures and 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
Conduct initial level medication prior‑authorization, exception and medical necessity reviews to determine coverage under the member’s benefit.
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, to determine the type of prior authorization review needed, and document any missing information.
Develop and implement process improvements to increase efficiency in the review process for the clinical staff.
Work with requesting providers, clinical pharmacists, and other internal staff to determine whether a case meets the criteria for approval according to policy and coverage criteria.
Contact pharmacies and physician offices to obtain clarification on prior authorization requests and drugs billed through the point‑of‑sale system or medical claim system.
Act as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy/medical claims with prior authorization information.
Ensure proper auth entry across all lines of business; interface care management system to claim processing system for claim payment, performing manual manipulation of auth when required.
Perform system testing for upgrades and enhancements to the care management system.
Serve as the content expert for prior authorization intake and act as the department’s subject matter expert for pharmacy and medical drug authorizations.
Act as the lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems, triaging issues to the appropriate department.
Triage prior authorization workflow daily by rerouting cases, alerting clinical staff of deadlines, monitoring queues and keeping management aware of compliance‑mandated deadlines.
Provide phone coverage for incoming calls to support the UM process, including authorization inquiries, claim inquiries and other related inquiries.
Support medical and pharmacy drug pricing questions using drug lookup tools such as government sites and other online resources.
Maintain thorough knowledge of health plan contracts, riders, policy statements and procedures to identify eligibility and coverage and assist staff with related inquiries.
Perform unit‑specific workflow processes consistent with corporate policies and regulatory agencies.
Produce or distribute information for others, track and report department performance against benchmarks.
Prepare and assist in handling correspondence, ensuring accuracy and timeliness.
Participate in interdepartmental coordination and communication to ensure consistent, quality health‑care services (e.g., Utilization Management, Quality Management, Case Management).
Consistently demonstrate high standards of integrity, supporting the company’s mission, values and code of conduct.
Maintain regard for member privacy per corporate privacy policies and procedures.
Maintain regular and reliable attendance.
Perform other functions as assigned by management.
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 with onboarding of junior staff and provide coaching as necessary.
Provide consistent positive audit results.
Work independently in coordinating and collaborating with members and providers to improve member and community health.
Manage complex assignments and detailed coordination between the medical and pharmacy benefits.
Display leadership and serve as a positive role model in the department.
Produce above‑team‑average medication prior‑authorization, exception and medical necessity reviews for the plan.
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.
Process management and documentation: identify, recommend and assess new processes to improve productivity.
Assist in updating departmental policies, procedures and desktop manuals.
Serve as backup to the supervisor for testing and implementing system upgrades.
Work directly with the operation and clinical staff to resolve issues and escalated problems; hold specialist designation.
Independently develop decision‑tree question‑set workflows and denial rationale based on policy criteria.
Own a Desk‑Level Procedure (DLP) for 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 maintaining the minimum average benchmarks for their level of experience.
Minimum Qualifications
High school diploma with a minimum of two years’ experience in a health‑related field (Associates degree preferred).
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Level II: basic understanding of medical terminology and diagnosis codes; drug classes and therapeutic interchange; prescription and medical benefits as it applies to the utilization review process; proficiency in Microsoft Office; strong verbal and written communication; professionalism, work ethics and a positive attitude; accuracy in prior authorization processing; customer‑service orientation; ability to work independently and apply problem‑solving skills.
Level III: 3–4 years of experience with health plan‑based prior authorization and claims processing systems; ability to work independently, mentor less experienced staff, and perform systems troubleshooting and technical liaison.
Physical Requirements
Work prolonged periods sitting at a workstation and using a computer.
Work while sitting/standing at a workstation for at least three hours.
Typical office environment with fluorescent lighting.
Work in a home office for continuity.
Travel across service regions as needed.
Ability to hear, understand and speak clearly while using a phone.
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.
Compensation Range
Level I: $19.22–$30.76
Level II: $20.02–$33.03
Level III: $21.83–$34.92
Remote work may be available on a case‑by‑case basis.
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