Pharmacy Prior Authorization Specialist - April 2026 Start Date

Primary Health Solutions•Hamilton, OH

About The Position

Pharmacy Prior Authorization Specialist Summary The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical information from electronic medical record, and timely communication with patients, prescribers and provider office staff. Candidates should possess knowledge of third-party reimbursement regulations and medical terminology as well as seek out assistance from a pharmacist as necessary. Success in this role will require strong communication, interpersonal, and problem-solving skills. This person should be able to interact and communicate effectively with internal and external customers, pharmacists, office staff, and all members of the organization.

Requirements

Certified Pharmacy Technician (CPhT) required. Proficiency in pharmacy practice.
Minimum of 3 years’ experience working as a Pharmacy Technician required.
Operate standard office equipment.
Maintains the security and confidentiality of data and information use in the performance of his/her daily duties conforming to health center policy, laws, and regulations as appropriate.
Handles telephone inquiries, and email referrals.
General knowledge of medical and pharmacy insurance plans, reimbursement and government regulations.
Developed knowledge of Microsoft Word and Excel
Self motivation and organizational skills
Developed knowledge of medications and medical terminology
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
To perform this job successfully, an individual should have the ability to gain knowledge of current electronic medical record, Intranet, Microsoft Word, Excel, PowerPoint, and Outlook.

Nice To Haves

Prior Authorization and/or Specialty Pharmacy experience preferred.

Responsibilities

Complete and submit prior authorizations for patients receiving medications prescribed by a Primary Health Solutions providers using Cover My Meds, and NextGen to ensure accurate information is being submitted.
Evaluates insurance coverage and pharmacy benefits to determine patient’s ability to pay for medications and identifies the need for additional coverage options such as copay cards based on the outcome of Prior Authorizations.
Maintains patient specific paper and/or electronic files to document all contact, correspondence, verification, and reason for denial for future reference through NextGen encounters.
Acts as a liaison between clinical and pharmacy teams and facilitates the triaging of patient needs.
Review prior authorization denials for appeal opportunities. Write and complete the appeal process in collaboration with the Primary Health Solutions pharmacy team.
Assists in the management of specialty medications in collaboration with our community partners.
Drive prescription volume to our in-house pharmacies where appropriate for patient’s benefit
Develop process improvements for expanding the prior authorization process and data collection.
Maintains effective communication and cooperative working relationships with other departments, pharmaceutical companies, members of medical and support staff, patients, and visitors.
Performs all other duties and tasks as assigned.