Who We Are - Motivated by Purpose. Powered by Clinical Expertise. Founded in 1983, we’re a clinically-driven, tech-enabled utilization management company offering expert clinical reviews, regulatory guidance, and actionable insights to healthcare organizations. Excellence starts with our people. WE OFFER

• A competitive compensation package.
• Benefits include healthcare, vision and dental insurance, a generous 401k match, paid vacation, personal time, and holidays.
• Growth and training opportunities.
• A team atmosphere with fun events and prizes scheduled throughout the year.

Position Summary

• Our Clinical Pharmacy Technician processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments.
• Performs analysis, obtains information, and enters prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based on clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.).
• Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality.

Roles

• Process and finalize PA requests within clients’ turnaround time (TAT) and Performance Guarantees (PGs) utilizing guidelines.
• Accountable for achieving prior authorization processing productivity and accuracy standards

Major Responsibilities or Assigned Duties

• Enter prior authorizations into the system and prioritize requests.
• Check formulary alternatives and review tried and failed medications.
• Utilize drug references and verify the drug being requested is indicated and approved for the condition.
• Document all related information regarding the PA approval or non-approval.
• Conform to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision-making. Partner with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing.
• Analyze, research, and resolve prior authorization processing issues, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from supervisor or clinical pharmacists; and referring unique or high dollar requests to supervisor according to guidelines.
• Coordinate within client system outbound communication to members, physicians, and pharmacies as required to obtain missing information and manage pending requests.
• Document prior authorization-related information and status.
• Make outbound calls to obtain information and answer questions about prior authorization status.
• Protect and maintain confidentiality and privacy of all prior authorization and member information, including following strict protocols for date stamping and storage/security of prior authorization forms and related information.
• Identify and recommend operational improvements.
• Participate in and support all applicable Quality Management initiatives
• Maintain a flexible schedule to meet client needs, as needed
• Adhere to all policies and procedures
• Take feedback and responsibility for performance
• Adapt to the differences of clients
• Support all Compliance Program activities
• Complete other duties and responsibilities as directed

Position Levels Each level attained compounds responsibilities with those of prior level(s). Clinical Pharmacy Technician I:

• Production should increase regularly, from 1-3 to 7 Prod steps/hour
• Quality should increase regularly, with expected minimum rate of 95%

Clinical Pharmacy Technician II:

• 3-month Production average should meet or exceed 7 Prod steps/hour (100%)
• 3-month Quality average should meet or exceed 96%
• No PIPs or CAPs in prior 3 months for any reason
• Completed all training checklists for department and demonstrated proficiency with position processes and PG clients
• Participate in the weekend rotation process
• Proficient with all position processes and team clients’ expectations
• Demonstrate ability to create training documents/presentations

Clinical Pharmacy Technician III:

• 3-month Production average should meet or exceed 8.3 Prod steps/hour (118%)
• 6-month Quality average should meet or exceed 98%
• No PIPs or CAPs in prior 6 months for any reason
• Effectively manage PANF reports, daily assignments, LOI, and Outreach calls
• Demonstrate problem solving and ability to work cross-functionally for new projects and HQs
• Demonstrate ability to train other PACs on HQ/processes and provide constructive feedback
• Effectively assist with monthly audits when asked
• Correctly approve PAC I-II Overdollar requests, as well as own
• Participate in special projects, lead committees, or pilot new processes/improvements

Clinical Pharmacy Technician IV:

• 3-month Production average should meet or exceed 9.7