Coverage Review Technician - Full-Time Employee or Contract (40 hours/week; contract up to 120 days)

Prescryptive Health, Inc.•Wyoming, MI

10d•$50,000 - $70,000•Remote

About The Position

The Coverage Review Technician supports the prior authorization and coverage determination process to ensure timely, accurate, and compliant decisions within Prescryptive’s pharmacy benefit management (PBM) operations. This role enables efficient medication access for members by executing PA reviews, maintaining documentation standards, and collaborating across teams to resolve coverage issues. The technician contributes to operational excellence, regulatory compliance, and continuous process improvement, including the adoption of automation and AI-enabled tools. Prescryptive is hiring for both Full-Time Employee roles and full-time Contract roles (up to 120 days)

Requirements

Active Pharmacy Technician License
High school diploma or GED.
2 years of experience in pharmacy operations, PBM, or related healthcare administration.
1+ years handling prior authorizations in a PBM, health plan, or clinical pharmacy setting.
Strong understanding of pharmacy operations and PBM workflows.
Proficiency in Microsoft Office Suite and PBM claims systems.
Experience with prior authorization process and using prior authorization platforms and managing clinical documentation.
Demonstrated expertise in HIPAA compliance and deep understanding of evolving prior authorization (PA) regulations and electronic PA standards.
Proven track record of enforcing the highest standards of privacy, security, and regulatory compliance in every aspect of work.
Proven experience leveraging AI and automation technologies to optimize coverage review and streamline decision-making processes.
Effective written and verbal communication skills.
Customer service orientation and professionalism in interactions with providers and internal teams.
Ability to work independently in a fast-paced, deadline-driven, metric-oriented environment.
Excellent attention to detail and organizational skills.

Nice To Haves

Associate’s degree or higher in healthcare or a related field.
Experience in a clinical call center or PBM operations environment.

Responsibilities

Review and process PA requests in alignment with clinical and operational criteria.
Communicate with provider offices to obtain necessary or clarifying information through appropriate channels (phone, fax, or electronic systems).
Enter determinations, overrides, and documentation accurately within PA and PBM platforms.
Maintain compliance with privacy, security, and regulatory requirements.
Collaborate with pharmacists, account managers, and customer support teams to address PA-related inquiries or escalations.
Identify recurring issues, data inconsistencies, or system barriers, and escalate for resolution.
Support improvement initiatives including the implementation of automation and AI-enabled tools that enhance workflow accuracy and turnaround.
Consistently meet or exceed established productivity and quality standards.