Role Overview: Responsible for processing pharmacy-related requests, ensuring members receive appropriate medications efficiently and cost-effectively.

Key Responsibilities: Handle calls from members, pharmacies, and providers regarding coverage, prior authorization, step therapy, networks, overrides, and denial reasons. Review and clarify incoming prior authorization requests, enter data into referral forms, and determine if requests require clinical pharmacist review based on plan policies. Prepare initial and denial letters, and act as a liaison with pharmacy benefit managers (PBMs) on pharmaceutical issues. Serve as a resource for other departments within the health plan. Meet performance benchmarks for prior authorizations, claims reviews, and communication volume.

Qualifications & Skills: High school diploma or equivalent required. Experience with inpatient and retail pharmacy utilization is preferred. Proficiency with multiple computer programs and strong communication skills are essential. Must be nationally certified as a Pharmacy Technician (CPhT) through PTCB or NHA, with specific certification and registration requirements depending on the state. Ability to work efficiently with various software programs and excellent interpersonal skills are necessary.