Position Summary:

Configure, maintain, and test prior authorization criteria, decision trees, and notification letters in the prior authorization system, analyze prior authorization data, and assist the Prior Authorization team with other duties as assigned.

Position Responsibilities:

• Maintain criteria source documents within the prior authorization system and in file sharing platforms for internal use
• Update PA criteria, new products, and associated product configurations in the prior authorization software within one week of receipt from formulary
• Assist the Prior Authorization Systems Pharmacists with the weekly new drug to market updates to include changes in GPI, MONY code, and NDC for existing current authorizations
• Responds to requests for clinical criteria from members and prescribers
• Maintenance of letter templates for external communications related to prior authorization review
• Manage and batch test prior authorization self-service functions and configurations including, but not limited to, TAT configurations, denial verbiage templates, and fax back messaging to ensure compliance with state, federal, and other regulations
• Utilize Microsoft Excel, Tableau, and other reporting software to analyze operational and systematic reports
• Monitor prior authorization volume and workforce in real time to recommend staffing adjustments applicable to real time performance and coordinate departmental schedules in conjunction with supervisors and managers to maximize service levels
• Create reports for production operations on existing and forecasted labor utilization
• Respond to internal team member issues related to criteria questions and setup
• Effectively communicate prior authorization system issues with appropriate internal stakeholders
• Prepare prior authorization requests received by validating prescriber and member information, level of review, and appropriate clinical guidelines.
• Proactively obtain clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Minimum Qualifications:

• Intermediate to advanced Microsoft Excel skills required
• 2+ years PBM or health plan experience in prior authorization required
• National Certified Pharmacy Technician (CPhT) license required
• Strong oral and written communication skills required
• Possess strong analytical and organizational skills, attention to detail, quantitative, and problem-solving abilities
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven work environment
• Ability to multi-task and collaborate in a team with shifting priorities

Preferred Qualifications:

• Experience managing UM criteria preferred
• JIRA, Salesforce, Tableau experience preferred
• Data analytics experience preferred
• Bachelor’s degree preferred