Pharmacy Authorization Representative II – BioPlus Specialty Pharmacy

Elevance Health

. Review the accuracy and completeness of prior authorization information and supporting documents .

Posted 10/20/2026full-timeUnited StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in processing pharmacy prior authorizations, including knowledge of Medicare, Medicaid, and Managed Care reimbursement guidelines. Proficient in critical thinking to interpret oncology regimens and supporting clinical documentation while collaborating effectively with various departments.

Highest-signal resume keywords

Prior Authorization ExperiencePharmacy Prior Authorization ProcessingMedicare KnowledgeMedicaid KnowledgeManaged Care Reimbursement Guidelines

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Prior Authorization ProcessingMedical Necessity DocumentationInsurance Denial ReviewAppeals SubmissionMedical TerminologyCritical ThinkingOncology Regimen InterpretationAuthorization Strategy DevelopmentDemographic Data CollectionDocumentation in Systems

Soft Skills

CollaborationCommunicationProblem-SolvingAnticipation of Payer Criteria

Certifications & Qualifications

HS DiplomaGED

Industry Keywords

Specialty Pharmacy ExperiencePayer CriteriaStep TherapySite-of-CareNCCN-Guided Rationale

About the role

Key responsibilities & impact

Review the accuracy and completeness of prior authorization information and supporting documents
Assist with medical necessity documentation to expedite approvals
Perform appropriate follow-up on prior authorization requests
Collaborate with other departments to obtain prior authorizations and appeals
Document insurance company interactions and prior authorization information in the system
Review insurance denials and submit appeals as permitted by payor
Contact physician offices to obtain demographic information or medical data
Administer prior authorization requests for patients whose health plans require drug prior authorizations across different therapy types

Requirements

What you’ll need

HS diploma or GED
Minimum of 2 years of experience processing pharmacy prior authorizations
Minimum of 1 year of experience applying knowledge of Medicare, Medicaid and Managed Care reimbursement guidelines
Any combination of education and experience which would provide an equivalent background
Specialty pharmacy experience highly preferred
Medical terminology training preferred
Prior Authorization experience highly desired
Critical thinking to interpret oncology regimens and supporting clinical documentation desired
Ability to anticipate payer criteria, including step therapy, site-of-care and NCCN-guided rationale
Ability to determine the best authorization strategy and next step
Candidates must reside within a reasonable commuting distance from a posting location unless an accommodation is granted
Candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

Benefits

Comp & perks

Merit increases
Paid holidays
Paid Time Off
Incentive bonus programs
Medical benefits
Dental benefits
Vision benefits
Short-term disability benefits
Long-term disability benefits
401(k) + match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources
Hybrid/virtual work flexibility
Professional and personal growth opportunities