AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.
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Position Summary:
The Senior Pharmacy Technician, Utilization Management leads the non-clinical administration of pharmacy utilization management (UM) programs by receiving, processing, and conducting non-clinical review of prior authorization requests, in accordance with established workflows, coverage criteria, and regulatory requirements, and escalating non-standard or ambiguous situations to a pharmacist. The role obtains required clinical and administrative information and serves as a liaison among providers, pharmacies, members, and internal departments to support accurate, efficient, and timely authorization processes. This position does not make clinical coverage determinations requiring pharmacist licensure; however, the role exercises discretion and independent judgment on non-clinical operational, workflow, and quality matters within UM, such as work prioritization, process gaps, and workflow improvements. In addition to performing pharmacy technician responsibilities, the Senior Pharmacy Technician serves as a subject matter expert and owner of day-to-day UM operations for the UM team. The role leads workflow coordination, training and quality oversight, and the resolution of non-clinical escalations, and serves as a super-user for UM technology.
What you will do:
Utilization Management Operations:
Receive, process, and conduct non-clinical review of pharmacy prior authorization requests and supporting documentation
Verify member eligibility, benefit coverage, authorization requirements, and applicable administrative information
Enter, update, and maintain authorization records within UM, pharmacy claims, and related systems
Obtain and document required information from providers, pharmacies, members, and other health care entities
Assess incoming prior authorization submissions for completeness and route them to the appropriate level of review, escalating to a pharmacist when standard criteria, business rules, or established workflows do not clearly apply
Prepare cases for pharmacist review and escalate requests requiring clinical judgment or a coverage determination in accordance with established workflows
Communicate authorization status, requests for additional information, and other non-clinical case information to providers, pharmacies, and members, as appropriate
Maintain accurate and complete documentation of case activities, communications, and outcomes
Monitor assigned work queues and prioritize requests to support compliance with applicable turnaround-time and notification requirements
Support appeals, reconsiderations, audits, quality initiatives, and regulatory or accreditation activities within the technician scope of responsibility
Protect confidential information and comply with HIPAA and all applicable federal, state, client, contractual, and organizational requirements
Operational Support and Coordination:
Serve as a subject matter expert for UM technicians regarding workflows, policies, procedures, benefit administration, and system functionality
Determine and manage workload distribution, queue prioritization, and coordination of urgent or time-sensitive requests across the UM technician team
Monitor workload, turnaround times, productivity, quality, and other operational performance indicators; analyze trends or barriers and determine and implement corrective action, reporting outcomes to UM leadership
Conduct quality reviews, identify recurring errors or workflow gaps, and…