JOB SUMMARY 

This role requires a strong understanding of pharmacy benefits, insurance processes, and patient access procedures. Responsibilities include the coordination and administration of effective and efficient processing for pharmacy benefits prior authorization processes, insurance evaluations, addressing patient medication access issues, performing medication reconciliation, and overseeing referral screening/management.

ESSENTIAL RESPONSIBILITIES 

• Prior Authorization & Utilization Management: Reviews pharmacy utilization management (UM) coverage requests for both pharmacy and medical benefits and prepares such cases for clinical review when required. Within the context of the request, applies plan-specific benefits to each case appropriately, summarizes pertinent facts, and cites applicable internal policies and guidelines. (40%)

• Patient & Provider Coordination: Resolves non-clinical issues independently and acts as a liaison between customers, provider-facing teams, and the Pharmacy Department. Engages in member and provider outreach to resolve issues such as appeal initiation requests, processing errors, and fulfilling notification requirements. Schedules appointments, verifies patient information, and addresses inquiries. Performs referral screening and processing, coordinating with specialists and ensuring timely patient access to necessary services. (30%)

• Data Management & Compliance: Responsible for all preauthorization entries into applicable databases (i.e., internal medical claims systems, PBM pharmacy systems) to ensure swift and appropriate payment of services deemed medically necessary. Conducts insurance evaluations to determine patient eligibility and coverage for services. Performs medication reconciliation tasks to ensure accurate medication lists and prevent potential drug interactions. Maintains regulatory compliance and resolves all cases within predetermined timeframes. Assists patients with applications to access affordable medications. (30%)

• Other duties as assigned or requested.

QUALIFICATIONS
Required 

•  2 years of experience as a Pharmacy Technician, Patient Access Coordinator, or Medical Assistant in health care setting

Preferred 

• Associate degree

• Certified Pharmacy Technician (CPhT) from Pharmacy Technician Certification Board

 
Language (Other than English): 

None 

Travel Requirement: 

0% - 25% 

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. 
 
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. 
 
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.  
 
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.