Pharmacy Utilization Management Specialist

Point32Health • Remote Worker Home Office (MA), MA

21h • $24 - $37

About The Position

Under the direction of the Supervisor, Pharmacy Utilization Management, the Pharmacy Utilization Management Specialist sets up and processes cases for drug prior authorization requests in various applications. The specialist reviews cases to ensure regulatory and accreditation requirements and turnaround times are met, documents cases that require pharmacist or medical director review, and supports approved authorizations through test claims and communication with members and providers. The role also involves handling provider inquiries and electronic prior authorization requests, completing quality checks, managing the team email box, and contributing process improvements. Other duties and projects may be assigned.

Requirements

• Certified Pharmacy Technician (CPhT).
• High school diploma or GED; an associate's degree in Healthcare, Nursing, or a related area, or equivalent experience, is also listed.
• At least 2 years of pharmacy experience.
• Ability to prioritize medical and pharmacy drug prior authorization requests according to guidelines and within required turnaround times.
• Ability to process high volumes of requests accurately.
• Attention to detail and ability to manage multiple demands and priorities in a fast-paced environment.
• Good working knowledge of medical terminology.
• Ability to work independently and as part of a team, and to interface regularly with staff and management at various levels.
• Ability to exercise appropriate judgment and follow applicable rules and regulations.
• Ability to work under normal office conditions and from home as required.
• Ability to use a telephone/headset and PC/keyboard simultaneously and sit for extended periods.
• Flexibility to work additional hours beyond the standard schedule; some early mornings, evenings, weekends, or extended workdays may be required as program needs dictate.

Nice To Haves

• Experience in a managed care or PBM setting.
• Experience with RxClaims and PAHub software/databases.
• Proficiency in Microsoft Office, including Excel, Word, and PowerPoint.

Responsibilities

• Set up cases from fax, electronic prior authorization (ePA), phone, and email requests.
• Review cases to ensure applicable regulatory and accreditation requirements and turnaround times are met.
• Document relevant case notes for prior authorizations requiring additional review by a pharmacist or medical director.
• Run test claims for approved authorizations and contact members and providers as necessary.
• Communicate with providers through the department phone queue to process phone prior authorizations and resolve inquiries.
• Perform daily quality checks to ensure compliance.
• Manage the Pharmacy UM team email box and electronic prior authorization requests.
• Respond to provider inquiries and submit process improvements.
• Perform other duties and projects as assigned.

Benefits

• Medical, dental, and vision coverage.
• Retirement plans.
• Paid time off.
• Employer-paid life and disability insurance, with additional buy-up coverage options.
• Tuition program.
• Well-being benefits.
• Benefits supporting career development, individual and family health, and financial health.
• Eligibility for variable pay; bonus or other compensation eligibility is at the Company's discretion.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED