Technician , Prior Authorizations

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

The Technician I, Prior Authorizations takes in-bound calls from providers, pharmacies, members, etc providing professional and courteous phone assistance to all callers through the criteria based prior authorization process. Maintains complete, timely and accurate documentation of reviews. Transfers all clinical questions, escalations and judgement calls to the pharmacist team.

The Tech I will also assist with other duties as needed to include but not limited to: outbound calls, reviewing and processing Prior Auth’s received via fax and ePA, monitoring and responding to inquiries via department mailboxes and other duties as assigned by the leadership team.

• Enters prior authorization requests submitted by healthcare providers, ensuring all required documentation is complete and accurate.
• Verifies insurance coverage to determine if prior authorization is required for specific medical procedures, treatments, or medications.
• Inspects medical records and clinical documentation to assess the medical necessity and appropriateness of the requested services or treatments.
• Assists in the preparation and submission of appeals for denied or rejected prior authorization requests, including gathering necessary supporting documentation.
• Documents relevant information into electronic systems, including patient details, medical codes, and prior authorization status.
• Communicates with team members and supervisors to identify process inefficiencies and propose solutions to streamline prior authorization operations.
• Communicates with healthcare providers to obtain additional information, clarify documentation, and communicate prior authorization decisions or requirements.
• Maintains awareness of updated industry regulations, medical coding guidelines, and changes in prior authorization requirements by participating in training sessions and knowledge-sharing activities.
• Ensures adherence to regulatory guidelines, company policies, and industry standards during the prior authorization process.

• 6 months of Customer Service/Pharmacy Technician Experience
• Regular and predictable attendance
• Colleague will be required to work mandatory overtime/extended work week when needed
• Colleague will be required to travel when needed
• Effectively manage work volume by handling inbound calls/fax requests utilizing appropriate courteous and professional behavior based upon established standards.
• Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.

High School Diploma or equivalent GED

• Long periods of sitting (up to 100%)
• Talking on the phone for extended periods of time (90-100%)
• Reading a computer screen for extended periods of time (100%)

Employee has a workspace that ensures compliance with CVS Health privacy and security policies and procedures. Information on computer screen must not be accessible or viewable by others. Telephone conversations involving confidential information must not be audible to others present in the home. Any CVS equipment or documents may not be accessible by others inside or outside of business hours. When a computer is not in use, it should remain locked or off, so confidential information is secure.

40

Full time

The Typical Pay Range For This Role Is

$17.00 - $28.46

This pay range represents the base hourly rate or base annual full‑time salary for all positions in the job grade within which this position falls. The actual base salary offer will…