Position Summary
The Prior Authorization (PA) Technician supports members' access to medications by processing and reviewing prior authorization requests in accordance with plan guidelines and clinical criteria. This role is highly phone-focused and requires comfort handling a high volume of inbound and outbound calls with healthcare providers, pharmacies, and members. The PA Technician is responsible for delivering timely, accurate service while maintaining compliance with regulatory standards and providing a positive customer experience.
• **PHONE HEAVY ROLE***
Job Responsibilities
• Process and review prior authorization requests to determine coverage eligibility based on plan guidelines and clinical criteria.
• Handle a high volume of inbound and outbound calls with providers, pharmacies, and members regarding prior authorization requests and determinations.
• Communicate prior authorization approvals, denials, and next steps in a professional, clear, and customer-focused manner.
• Collaborate with healthcare providers to obtain required clinical documentation and clarify prescription needs.
• Respond to inquiries, resolve issues, and provide education regarding prior authorization requirements and processes.
• Maintain accurate and detailed documentation of calls, approvals, denials, and follow-up activities.
• Assist with appeals, reconsiderations, and escalated cases as needed.
• Meet established productivity, quality, and service expectations, including call handling and response time metrics.
• Identify opportunities to improve workflows and enhance the member and provider experience.
• Ensure compliance with all regulatory requirements, client guidelines, and internal policies.
• Perform other related duties as assigned.
Required Experience
• High school diploma or equivalent.
• 1+ years of experience in a pharmacy, PBM, healthcare, customer service, or call center environment.
• Active certification from the Pharmacy Technician Certification Board (PTCE) or the National Healthcareer Association (NHA).
• Knowledge of prior authorization processes, pharmacy benefits, and insurance guidelines.
• Strong verbal communication skills and professional phone presence.
• Ability to confidently handle frequent inbound and outbound calls throughout the workday.
• Excellent customer service, problem-solving, and relationship-building skills.
• Strong attention to detail, organization, and documentation skills.
• Ability to multitask effectively between phone conversations, systems, and administrative work.
Work Environment
• Remote or office-based call center environment with frequent phone and computer use.
• Daily interaction with healthcare providers, pharmacies, members, and internal stakeholders.
• Fast-paced environment requiring the ability to manage multiple priorities while maintaining a high level of service.
• Regular participation in team meetings, training sessions, and quality reviews.
Physical Demands
• Regularly required to sit for extended periods, use hands to operate a computer and telephone equipment, and communicate effectively by phone and video.
• Frequently required to view computer screens and navigate multiple systems simultaneously.
• Occasionally required to stand, walk, bend, or reach.
• Specific vision abilities include close vision and the ability to adjust focus.