Senior Pharmacy Technician, Utilization Management

This is a fully remote position, open to applicants in United States.

📋 Description

• Receive, process, and perform a non-clinical review of pharmacy prior authorization requests along with their supporting documentation.

• Verify member eligibility, benefit coverage, authorization requirements, and administrative details.

• Enter, update, and maintain authorization records in Utilization Management (UM), pharmacy claims, and associated systems.

• Collect and document necessary information from providers, pharmacies, members, and other healthcare entities.

• Evaluate the completeness of submissions, direct requests to the appropriate review level, and escalate non-standard cases to pharmacists.

• Prepare cases for pharmacist review and communicate the authorization status or requests for additional information.

• Ensure comprehensive documentation of case activities, communications, and outcomes.

• Monitor work queues and prioritize requests to meet turnaround time and notification requirements.

• Assist with appeals, reconsiderations, audits, quality initiatives, and regulatory or accreditation activities.

• Act as a subject matter expert for UM technicians regarding workflows, policies, procedures, benefits administration, and system functionalities.

• Oversee workload distribution, queue prioritization, and urgent requests among the UM technician team.

• Track operational performance indicators, analyze obstacles, implement corrective actions, and report outcomes to UM leadership.

• Conduct quality reviews and provide coaching, feedback, training, onboarding, and mentoring.

• Develop and sustain technician workflows, standard operating procedures, job aids, and training materials.

• Investigate and address non-clinical authorization issues, workflow conflicts, and inquiries from providers or pharmacies.

• Serve as a super-user for prior authorization technology and associated UM systems.

• Lead configuration, testing, validation, implementation, maintenance, formulary updates, UM programs, system enhancements, and client-specific workflows.

• Collaborate with pharmacists, UM leadership, operations, clinical configuration, claims, and technology teams.

• Identify and enact process improvements and support audit preparation, accreditation readiness, corrective actions, and compliance initiatives.

⛳️ Requirements

• Bachelor’s degree in Healthcare Administration, Business Administration, Pharmacy, Health Sciences, or a related field.

• 5+ years of experience as a pharmacy technician, with at least 3 years in UM, managed care, pharmacy benefit manager (PBM), health plans, or similar pharmacy benefit operations.

• Active pharmacy technician registration, licensure, or other credentials required by the state(s) where the employee provides services.

• Current Certified Pharmacy Technician (CPhT) credential.

• Prior experience in a senior technician, trainer, quality reviewer, or workflow coordinator role.

• Experience in supporting operational configuration, user acceptance testing, validation, implementation, or maintenance of prior authorization or UM technology platforms.

• Background in pharmacy benefit configuration, formulary changes, clinical program implementation, audits, or process improvement initiatives.

• Familiarity with NCQA, URAC, ERISA, state-specific, or other relevant utilization management and pharmacy benefit requirements.

• Proven experience in training, mentoring, coaching, or coordinating the work of others.

• Working knowledge of pharmacy prior authorization operations, pharmacy benefits, formulary management, exception processing, and appeals support.

• Proficiency in using utilization management platforms, pharmacy claims systems, and Microsoft Office applications.

• Strong analytical, organizational, written and verbal communication, customer service, and problem-solving abilities.

• Capability to exercise judgment and discretion in ambiguous or non-standard operational situations and escalate issues requiring pharmacist review.

• Demonstrated ability to make independent decisions in resolving significant operational matters without prior approval.

• Ability to handle multiple priorities, meet turnaround time expectations, and maintain accuracy and attention to detail in a fast-paced environment.

• Capacity to work independently and collaboratively across clinical, operational, and technical teams.

• Ability to maintain confidentiality and appropriately manage protected health information (PHI).

• A dedicated, private, and secure remote work environment that meets organizational standards.

• Willingness to travel 10–20%.

🏝️ Benefits

• Competitive compensation package, including health, dental, vision, and additional benefits.

• Opportunity to influence industry change in the pharmacy benefits management sector while ensuring high-quality patient outcomes.

• A culture that fosters personal and professional growth.

• Remote work arrangement.