RESPONSIBILITIES

Prepares pharmacy prior authorization requests for review by nurse/pharmacist/physician reviewers. Completes pharmacy authorization requests and issues review outcome notifications to Community First Health Plans (CFHP) members and providers. Follows clinical criteria and instructions to approve prior authorization requests based on established criteria, plan policies and procedures. Performs non-medical research including eligibility verification and benefits verification. Reviews medication utilization reports and identifies trends through advanced data analytics. Produces reports to comply with regulatory and accreditation standards

EDUCATION/EXPERIENCE

Graduation from high school/GED required. Bachelor’s degree preferred. Five years of pharmacy experience required. Some coursework at the college level is preferred. Excellent customer service, phone etiquette, attention to detail, and typing skills is required. Basic knowledge of Microsoft Office and internet required. Experience in health insurance/pharmacy insurance or managed care organization preferred. Prior authorization processing experience desired. Experience in a PBM or managed care call center desired. Knowledge of InterQual screening criteria as well as DRG, ICD-10 and CPT coding is preferred.

LICENSURE/CERTIFICATION

Texas State Board of Pharmacy registration required. Certification as a Pharmacy Technician (CPhT) is required.