Clinical Prior Authorization Technician (Temp to Hire)

Location:Remote (U.S only)

Position Summary

A UM Technician IIpreparescomplex prior authorization requests byidentifyingclinical 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 usesproblem solving skills toidentifygaps and obtain relevant details to resolve client, member, pharmacy personnel, and provider concerns. The role alsoassistsleadership with departmental projects.

Position Responsibilities:

• Prepare complex prior authorization requests byidentifyingclinicalguidelinesfor reviewandensuringsubstantialclinical informationexiststo reach aclinicaldeterminationforpharmacist review.

• Proactively obtains clinical information from prescribers, referral coordinators, andappropriate staffto ensure all aspectsof clinical guidelines are addressed for pharmacist review.

• Effectively use problem solving skills toidentifygaps and obtain relevant details to resolve client, member, pharmacy personnel, and providerconcerns.

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

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

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

• Effectively communicate issues and resolutions to members, pharmacy staff, providers, andappropriate internalstakeholders.

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

• Receive requests fromcallcenter andperformsinitialreviewfor prior authorization and formulary exception requests based onestablishedclinical and contract criteria.

• Assistwith departmental projects.

• Follow all internal Standard Operating Procedures.

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

Required Qualifications:

• Minimum of 1 year of experience as a UMTechnicianI at Capital Rx

• State orNational Certified Pharmacy Technician (CPhT) licenserequired.

• High school diploma orthe equivalent;Associate's or bachelor'sdegree 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 rangerepresentsthe low and high end of theanticipatedbase salary range for the NY - based position. The actual base salary will depend on several factorssuch 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.