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Open nowFirst seen 4 days ago

Prior Authorization Guideline Specialist

Nexus Recruitment Group310 open roles

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Your applicationOpen nowPrior Authorization Guideline SpecialistNexus Recruitment Group

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Share of postings closed within
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  2. 4.5%3 days
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  4. 19.3%14 days
  5. 35.6%30 days
  6. 57.8%60 days
This job: first seen 4 days ago

The posting

Job description:

Locations: Cebu / Makati, Philippines (2 Openings – 1 per site) Employment Type: Full-time Start Date: Can start ASAP

Job Overview

We are seeking a detail-oriented Prior Authorization Guidelines Specialist to provide technical and administrative support to the Fee-For-Service (FFS) Medicaid pharmacy operations team. This role works closely with Clinical Account Executives, Clinical Specialists, and Pharmacy Prior Authorization (PA) and Drug Information teams to ensure accurate development, maintenance, and implementation of Medication Request Guidelines and related clinical documentation.

The role plays a key part in supporting Prior Authorization (PA) processes, guideline management, and electronic rule implementation used in pharmacy benefit operations.

Key Responsibilities

  • Develop, update, and maintain Prior Authorization (PA) Guideline documents, including content management, version control, and archiving
  • Support the creation and formatting of Medication Request Guidelines and Medication Request Forms (MRFs)
  • Assist in the development and testing of electronic PA rules and system configurations
  • Coordinate with internal teams and external clients to ensure accuracy and approval of final guideline documents
  • Ensure timely distribution of updated clinical documentation to relevant departments
  • Perform quality assurance (QA) review of PA guidelines prior to implementation
  • Provide support for PA-related research, implementation, and documentation updates
  • Serve as a subject matter support resource for PA guidelines and pharmacy benefit processes
  • Maintain organized documentation systems and ensure compliance with internal standards and workflows
  • Communicate effectively with clients regarding updates, approvals, and documentation requirements

Qualifications

  • Associate degree or equivalent (CL05 requirement preferred)
  • At least 2 years of relevant experience in healthcare, pharmacy, insurance, or clinical operations
  • Must hold a valid Pharmacy Technician License and/or CPhT certification (or equivalent state licensure in the U.S. or its territories)
  • Experience with managed pharmacy benefits, prior authorization, formulary management, or claims processing is an advantage

Technical Skills

  • Proficient in MS Office (Word, Excel, Outlook)
  • Familiarity with Windows-based database systems
  • Ability to learn new systems and tools quickly
  • Strong attention to detail in documentation and data handling

Soft Skills & Competencies

  • Strong customer service and communication skills (written and verbal)
  • Ability to work independently and in a team environment
  • Strong time management and organizational skills
  • Problem-solving and critical thinking abilities
  • Ability to manage multiple priorities and deadlines
  • Adaptability in a fast-paced, regulated environment
  • Professionalism in handling client-facing interactions

Core Knowledge Areas (Preferred)

  • Prior Authorization (PA) processes
  • Pharmacy benefit management (PBM) concepts
  • Formularies, claims adjudication, and medication edits
  • Clinical documentation workflows
  • Quality assurance and guideline compliance

Work Locations

  • Cebu – 1 opening
  • Makati – 1 opening

Work Location: Hybrid remote in Makati

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