The Associate Clinical Operations Technician is responsible for processing, communicating, documenting and tracking requests for formulary exceptions, prior authorizations, quantity exceptions, and brand override for delegated utilization management (UM) products and services.
*VARIOUS SHIFTS AVAILABLE*
- Review criteria to determine if the request can be approved
- Accurately enter Prior Authorization in claims system to ensure appropriate claims will adjudicate
- Respond to completed requests by creating written communication of the clinical outcome to the member and the member’s physician within client specific turnaround times
- Research and respond to calls and emails
- Perform outreach to pharmacies and physician’s offices related to the department process across multiple clients to obtain all necessary information related to UM requests, including occasional member assistance
- Provide all relevant clinical information specific to a UM request to a department Pharmacist and the Physician
- Manage work queue and volumes to meet client specific turnaround times
- Other duties as assigned
- Commercial: Responsible to be proficient in one area (i.e., intake, research, etc.); area assignment is based on department need
- Government Programs: Responsible to be proficient in single review, approval/denial, etc.
- Strong verbal and written communication skills, interpersonal skills, and attention to detail
- Demonstrated organizational and time-management skills
- Willingness and ability to learn internal systems/processes/programs as needed
- Ability to work overtime, weekends and holidays on a rotating basis as needed
- Basic math skills and general PC knowledge including Microsoft Office, Internet, and email.
- Ability to work a flexible schedule to accommodate business needs
- Associate’s degree in business or related area of study, or equivalent combination of education and/or relevant work experience
- National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
- PBM/health care experience
Minimum Physical Job Requirements
- Constantly required to sit, use hands to handle or feel, talk and hear
- Frequently required to reach with hands and arms
- Occasionally required to stand, walk and stoop, kneel, and crouch
- Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus
- Reports to Supervisor in the Clinical Review department
Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage qualified minority, female, veteran, disabled, and other diverse candidates to apply and be considered for open positions.