Job Description:
• Take inbound calls from providers, pharmacies, members, and other callers
• Provide professional and courteous phone assistance through the criteria-based prior authorization process
• Maintain complete, timely, and accurate documentation of reviews
• Transfer clinical questions, escalations, and judgment calls to the pharmacist team
• Make outbound calls as needed
• Review and process prior authorizations received via fax and ePA
• Monitor and respond to inquiries through department mailboxes
• Enter prior authorization requests and verify required documentation
• Verify insurance coverage to determine whether prior authorization is required
• Inspect medical records and clinical documentation for medical necessity and appropriateness
• Assist with appeals for denied or rejected prior authorization requests
• Document patient details, medical codes, and authorization status in electronic systems
• Identify process inefficiencies and propose improvements
• Communicate with healthcare providers to obtain information, clarify documentation, and communicate decisions or requirements
• Stay current on industry regulations, medical coding guidelines, and prior authorization requirements
• Follow regulatory guidelines, company policies, and industry standards
Requirements:
• 6 months of Customer Service/Pharmacy Technician Experience
• High School Diploma or equivalent GED
• Regular and predictable attendance
• Willingness to work mandatory overtime/extended work week when needed
• Willingness to travel when needed
• Ability to manage work volume by handling inbound calls/fax requests using courteous and professional behavior
• Compliance with departmental, company, state, and federal requirements when processing information
• Ability to maintain a privacy- and security-compliant home office workspace
• Ability to protect confidential information from being viewed or heard by others in the home
• Ability to sit for long periods, up to 100%
• Ability to talk on the phone for extended periods, 90–100%
• Ability to read a computer screen for extended periods, 100%
Benefits:
• CVS Health bonus, commission or short-term incentive program in addition to base pay
• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being
• Home-based work environment