Job Description:
• Process prior authorization requests received by phone, fax, or electronically
• Use computer resources, existing criteria, and medication guidelines to perform clinical research supporting prior authorization reviews
• Complete prior authorization approvals and denials due to expire
• Maintain complete, timely, and accurate documentation
• Review potential prior authorization denial language to ensure NCQA requirements are met
• Follow prior authorization workflows, policies, and procedures
• Answer high-volume prior authorization inquiry calls from provider offices, pharmacies, and internal partners
• Communicate prior authorization status or decisions using multiple computer resources
• Balance productivity, quality, and timeliness
• Participate in required training, continuing education, and team or departmental meetings
• Recognize drug names and diagnoses, medical terminology, and navigate multiple computer resources to document conversations and decisions
Requirements:
• National Pharmacy Technician certification and applicable state Pharmacy Technician license, current and in good standing, are required and must be maintained
• Between 1-5+ years of Pharmacy Prior Authorization processing experience
• Ability to multi-task and prioritize work
• Ability to adjust based on business or department needs
• Good organization skills
• Retail or Hospital experience preferred
• Managed Care or Medicaid experience preferred
• AS400 experience preferred
• Proficiency in using computerized resources and software applications preferred
• Proficiency with Microsoft applications (Excel, Word, and Outlook) preferred
• Knowledge in pharmacy practices and procedures, and ability to read and understand clinical information preferred
• Working knowledge of drug dosage forms, drug strength, generic and brand name equivalent preferred
• High School diploma or G.E.D.
• Own home internet access with minimum speed of 100 Mbps download
• Secure workspace/office in the home
• High level skill working with a PC and navigating multiple systems and screens
• Ability to work 40 hours per week as scheduled, including weekends and holidays
• Ability to work extended hours when necessary
• Rotating weekend schedule may be required
Benefits:
• CVS Health bonus, commission or short-term incentive program in addition to the base pay range
• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being, based on eligibility