Remote Pharmacy Technician - Prior Auth Review

Job Title:

Pharmacy Technician

Job Description

The Pharmacy Technician supports a wide range of pharmacy operations, including formulary management, pharmacy audit and recovery, pharmacy service center activities, Medicare Part D and Part B processes, appeals, state health programs pharmacy operations, prior authorizations, and oversight and audit support. Using established guidelines, this role reviews and processes requests from physicians, medical groups, pharmacies, and members for prescription drugs and pharmacy benefits, researches and resolves issues, and collaborates with clinical pharmacists and other stakeholders to ensure accurate, compliant, and member-focused pharmacy services.

Responsibilities

* Review rejected prior authorization cases that have gone to appeal, with a focus on medical authorizations and injectable therapies administered in provider offices.

* Access and manage the department's inbound fax queue by selecting the earliest available fax and accurately building or intaking appeal and reimbursement requests into the member's account.

* Log into and work within CPS Compass, UMV, and Express Scripts platforms to process pharmacy appeals and reimbursement cases.

* Review pharmacy appeals and reimbursement cases against established plan criteria to determine completeness and identify any missing or unclear information.

* Perform high-volume, accurate data entry to document appeal details, case notes, and outcomes in the appropriate systems.

* Make outbound calls to provider offices and members to obtain additional clinical or administrative information needed to complete appeal reviews.

* Handle inbound calls from provider offices and members who return calls or seek updates on their appeals or reimbursement requests.

* Ensure all cases are processed within tight turnaround times and compliance deadlines, escalating issues when necessary to avoid delays.

* Maintain a high level of attention to detail and quality in all documentation, data entry, and case review activities.

* Use Microsoft Office applications, including Outlook, to manage communications, organize work, and track case progress.

* Follow departmental procedures and quality standards, including auditing and self-review of work to ensure accuracy.

* Participate in ongoing training and continuous learning to stay current on plan criteria, system updates, and process changes.

* Work independently in a remote environment while meeting productivity, accuracy, and quality expectations.

* Collaborate with team members and leadership as needed to support process improvements, share best practices, and contribute to a positive team culture.

Essential Skills

* High school diploma or GED.

* At least 1 year of experience as a Pharmacy Technician.

* Experience in pharmacy data entry and processing of prescription claims.

* Experience handling prior authorization requests and related inquiries.

* Ability to review and interpret pharmacy benefits, formularies, and prior authorization criteria.

* Strong attention to detail when auditing claims, reviewing formulary status, and maintaining databases.

* Effective verbal and written communication skills for interacting with members, providers, pharmacies, and internal teams.

* Ability to research and resolve questions, problems, and issues using appropriate reference materials.

* Proficiency in using databases and systems, including updating Access databases and PBM systems.

* Customer service skills, including handling member and provider inquiries in a professional manner.

Additional

Skills & Qualifications

* Customer service or retail experience preferred.

* Valid Pharmacy Technician license preferred.

* Experience with appeals processes in a pharmacy or health plan environment.

* Familiarity with Medicare Part D and Part B pharmacy benefits and regulations.

* Experience with state health programs pharmacy operations, including Medi-Cal, is an advantage.

* Ability to participate in regulatory change implementation and audit preparation.

* Comfort working with operational reports, audits, and compliance documentation.

Work Environment

The role is based in a structured pharmacy operations environment that involves extensive use of computers, databases, and claims processing systems, including PBM platforms and Access databases. You will regularly interact by phone, fax, and email with members, providers, pharmacies, and internal departments, working within established policies, procedures, and regulatory requirements. The position focuses on accuracy, compliance, and timely processing of requests and claims, and may involve periods of high call volume and detailed audit work.

This position is 100% remote with a work schedule of Monday-Friday 10am-6:30pm in your time zone.

Job Type & Location

This is a Contract to Hire position based out of Pittsburgh, PA.

Pay and Benefits

The pay range for this position is $18.00 - $23.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of…