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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in prior authorization processes, clinical decision-making, and effective communication with stakeholders. Proficient in managing multiple requests and navigating complex benefit plans while adhering to protocols.
Highest-signal resume keywords
Active Pharmacy Technician LicensePrior Authorization Review ExperienceClaims ProcessingCritical ThinkingMac, MS Office, and G-Suite Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AdjudicationClinical Review ProcessesMedication Policy EvaluationWorkflow AssessmentBasic Calculations
Soft Skills
Active ListeningEmpathyTime ManagementClear CommunicationMultitasking
Certifications & Qualifications
High School Diploma or GED
Industry Keywords
Pharmacy Benefit Manager (PBM)Drug CoveragePrior AuthorizationClinical Decision-MakingStakeholder Outreach
About the role
Key responsibilities & impact- Verify eligibility and drug coverage under plan benefit designs to determine appropriate claims processing
- Triage clinical review processes for prior authorization requests according to established protocols
- Review prior authorization and similar requests using criteria, claims history, and plan benefit rules
- Conduct prescriber and pharmacy outreach to verify and gather required information
- Organize and prioritize multiple requests for timely prior authorization case management
- Build and adjust authorizations within the claim adjudication system
- Navigate drug products and formulations and perform basic calculations to monitor accurate claims adjudication
- Assess and synthesize multiple workflows to make sound clinical decisions
- Coordinate outreach across teams and address questions and escalations
- Evaluate member clinical situations against medication policies and approve or triage cases to a Pharmacist for denial
- Determine when medications require internal or external review
- Contact selected external stakeholders for approval on drugs with dollar limits
Requirements
What you’ll need- High School diploma or GED or equivalent work experience
- Active Pharmacy Technician license required
- 2-4 years of experience as a Pharmacy Technician
- Experience in prior authorization review at a PBM or health plan preferred
- Proficiency in Mac, MS Office, and G-Suite required
- Critical thinking to navigate complex customized benefit plans
- Active listening and conversational speaking skills, with a high degree of empathy
- Ability to multitask, prioritize, and manage time effectively
- Ability to communicate clearly and present complex information to members, clients, pharmacies, providers, and internal teams
- Ability to work accurately within protocols and follow appropriate escalation pathways
Benefits
Comp & perks- Bonuses, commissions, or equity may be available
- Time off programs
- Medical insurance
- Dental insurance
- Vision insurance
- Mental health support
- Paid parental leave
- Life insurance
- Disability insurance
- 401(k)