Sr Prescription Benefit Prior Authorization Technician Specialty (hybrid)

PURPOSE OF THE JOB

• Responsible for internal and external support functions that contribute to accurate claim processing for medications

• Responsible for processing medication prior authorization requests from providers as well as answering incoming phone calls related to escalated issues and prior authorization request clarification

Qualifications

REQUIRED QUALIFICATIONS

Required Work Experience

• Level 1 - 1 year experience in pharmacy or medical field (eg pharmacy, health insurance, medical office, etc)
• Level 2 - 2 years’ experience in pharmacy or medical field (eg pharmacy, health insurance, medical office, etc) AND 1 year experience in Pharmacy Prior Authorization Intake & Processing
• Level 3 - 3 years’ experience in pharmacy or medical field (eg pharmacy, health insurance, medical office, etc) AND 2 years’ experience in Pharmacy Prior Authorization Intake & Processing AND 1 year experience working on Specialty Pharmacy reviews including Medical Reviews
• Level 4 - 10 years’ experience in pharmacy or medical field (eg pharmacy, health insurance, medical office, etc) AND 4 years’ experience in Pharmacy Prior Authorization Intake & Processing AND 2 years’ experience working on Specialty Pharmacy reviews including Medical Reviews

 Required Education

• High-School Diploma or GED

 Required Licenses

• Within 9 months of entry into the role, must obtain and keep current an AZ State Board Pharmacy Technician license

Required Certifications

• Within 9 months of entry into the role, must obtain and keep current a Pharmacy Technician Certification Board (PTCB) Certification.

PREFERRED QUALIFICATIONS

Preferred Work Experience

• Level 1 - 3 years’ experience with a pharmacy benefit management or prescription claim administration AND 1 year experience in Prior Authorization AND 1 year experience with the current BCBSAZ PBM system AND 2 years’ demonstrated experience handling confidential information
• Level 2 -  3 years’ experience with a pharmacy benefit management or prescription claim administration AND 2 years’ experience in Prior Authorization AND 1 year experience with the current BCBSAZ PBM system AND 3 years’ demonstrated experience handling confidential information
• Level 3 - 5 years’ experience with a pharmacy benefit management or prescription claim administration AND 3 years’ experience in Prior Authorization AND 2 years’ experience with the current BCBSAZ PBM system AND 1 year experience with BCBSAZ claims software/systems Medical & Pharmacy AND 4 years’ demonstrated experience handling confidential information
• Level 4 - 12 years’ experience with a pharmacy benefit management or prescription claim administration AND 10 years’ experience in Prior Authorization AND 3 years’ experience with the current BCBSAZ PBM system AND 2 years’ experience with BCBSAZ claims software/systems Medical & Pharmacy AND 10 years’ demonstrated experience handling confidential information

Preferred Education

• N/A

Preferred Licenses

• N/A

Preferred Certifications

• Pharmacy Technician Certification

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

ALL LEVELS:

• Process Prior Authorization Reviews including intake, clarification, approvals, denials, exclusions, or another exceptions as assigned
• Adhere to standard, urgent and exigent turnaround times for exception request & prior authorization request notifications to members & providers
• Answer internal & external phone calls regarding prior authorization clarifications and benefit clarification escalations
• Participate in projects that support the evolution of high value prescription benefits
• Participates in quality initiatives; including functions that support audits, reporting, evaluation of quality opportunities and concerns, and creation and implementation of corrective actions as requested.
• Interpret and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals
• Meet department defined production & quality metrics for Level
• The position requires a full-time work schedule.  Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.

LEVEL 2 - ADDITIONAL JOB FUNCTIONS UNDER CLOSE SUPERVISION OR PEER REVIEW

• Provide Prior Authorization recommendations to reviewing RPhs based on benefit plan design and pharmacy coverage guidelines
• Assist in defining and improving the quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
• Communicate recommendations in regard to medication prior authorization processing and benefit decisions.

LEVEL 3 - ADDITIONAL JOB FUNCTIONS UNDER MINIMAL SUPERVISION

• Provide Prior Authorization recommendations to reviewing RPhs based on benefit plan design, pharmacy coverage guidelines and medical coverage guidelines
• Setup & process all specialty medication reviews regardless of being utilized under the pharmacy or medical benefit
• Maintain a working knowledge of all pharmacy and medical claims processing systems
• Subject matter experts regarding prior authorization with a focus on Specialty Prior Authorization, precertification and some retrospective reviews

COMPETENCIES