The posting
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.
Join us in improving health care outcomes for all! We promise to do what’s right, always.
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 provide coaching, feedback, and training to support accuracy, consistency, and compliance
- Support onboarding, mentoring, and ongoing development of new and existing UM technicians
- Develop, maintain and operationalize technician workflows, standard operating procedures, job aids, and training materials.
- Investigate and resolve non-clinical authorization issues, workflow conflicts, and provider or pharmacy inquiries, exercising discretion to determine the appropriate resolution
- Serve as a day-to-day resource for UM technicians by providing guidance on established workflows, priorities, and non-clinical operational questions; resolve non-clinical matters and escalate clinical or coverage questions to a pharmacist and operational concerns to UM leadership
- Provide backup support for designated operational leadership functions, as assigned
Technology, Implementation, and Process Improvement:
- Serve as a super-user for the prior authorization technology platform and related UM systems
- Lead operational configuration, user acceptance testing, validation, implementation, and ongoing maintenance of prior authorization technology platforms
- Lead implementation of formulary updates, utilization management programs, system enhancements, and client-specific workflows
- Collaborate with pharmacists, UM leadership, operations, clinical configuration, claims, and technology teams to investigate and resolve workflow or system issues
- Identify opportunities to improve efficiency, accuracy, service, and the user experience; assist with development and implementation of sustainable process improvements
- Support audit preparation, accreditation readiness, corrective-action activities, and compliance initiatives
What you need:
- Bachelor’s degree in Healthcare Administration, Business Administration, Pharmacy, Health Sciences, or a related field
- 5+ years of pharmacy technician experience, including at least 3 years in UM, managed care, PBM, health plan, or comparable pharmacy benefit operations
- Active pharmacy technician registration, licensure, or other credential required by the state(s) in which the employee performs services
- Current Certified Pharmacy Technician (CPhT) credential
- Prior experience in a senior technician, trainer, quality reviewer, or workflow coordinator capacity
- Experience supporting operational configuration, user acceptance testing, validation, implementation, or maintenance of prior authorization or UM technology platforms
- Experience supporting pharmacy benefit configuration, formulary changes, clinical program implementation, audits, or process-improvement initiatives
- Familiarity with NCQA, URAC, ERISA, state-specific, or other applicable utilization management and pharmacy benefit requirements
- Demonstrated experience 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
- Experience using utilization management platforms, pharmacy claims systems, and Microsoft Office applications
- Strong analytical, organizational, written and verbal communication, customer service, and problem-solving skills
- Ability to exercise judgment and discretion to resolve ambiguous or non-standard operational situations, and to recognize and escalate matters that require pharmacist review
- Demonstrated ability to exercise discretion and independent judgment in resolving operational matters of significance without prior approval
- Ability to manage multiple priorities, meet turnaround-time expectations, and maintain accuracy and attention to detail in a fast-paced environment
- Ability to work independently and collaboratively across clinical, operational, and technical teams
- Ability to maintain confidentiality and appropriately handle protected health information (PHI)
- Dedicated, private, and secure remote work environment that meets organizational requirements
- Willingness to travel 10-20%
What you get:
- To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
- To work in a culture where people thrive because when OUR team thrives, OUR business thrives
- Competitive compensation, including health, dental, vision and other benefits
Note:
AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.
