Technician I, Prior Authorizations

CVS Health•Work At Home-Virginia, VA

3d•$17 - $28•Remote

About The Position

The Technician I, Prior Authorizations takes in-bound calls from providers, pharmacies, members, etc providing professional and courteous phone assistance to all callers through the criteria based prior authorization process. Maintains complete, timely and accurate documentation of reviews. Transfers all clinical questions, escalations and judgement calls to the pharmacist team. The Tech I will also assist with other duties as needed to include but not limited to: outbound calls, reviewing and processing Prior Auth’s received via fax and ePA, monitoring and responding to inquiries via department mailboxes and other duties as assigned by the leadership team.

Requirements

6 months of Customer Service/Pharmacy Technician Experience
Regular and predictable attendance
Colleague will be required to work mandatory overtime/extended work week when needed
Colleague will be required to travel when needed
Effectively manage work volume by handling inbound calls/fax requests utilizing appropriate courteous and professional behavior based upon established standards.
Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.

Responsibilities

Enters prior authorization requests submitted by healthcare providers, ensuring all required documentation is complete and accurate.
Verifies insurance coverage to determine if prior authorization is required for specific medical procedures, treatments, or medications.
Inspects medical records and clinical documentation to assess the medical necessity and appropriateness of the requested services or treatments.
Assists in the preparation and submission of appeals for denied or rejected prior authorization requests, including gathering necessary supporting documentation.
Documents relevant information into electronic systems, including patient details, medical codes, and prior authorization status.
Communicates with team members and supervisors to identify process inefficiencies and propose solutions to streamline prior authorization operations.
Communicates with healthcare providers to obtain additional information, clarify documentation, and communicate prior authorization decisions or requirements.
Maintains awareness of updated industry regulations, medical coding guidelines, and changes in prior authorization requirements by participating in training sessions and knowledge-sharing activities.
Ensures adherence to regulatory guidelines, company policies, and industry standards during the prior authorization process.