Pharmacy Mail Order Prior Authorization Specialist (PTCB Required)

Responsibilities: Precertify eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity. Review clinical information submitted by providers to evaluate necessity, appropriateness, and efficiency of prescription use. Verify physician orders and determine CPT, HCPCS, and ICD‑10 codes for prior authorization. Contact insurance companies and third‑party administrators to gather information and coordinate workflow. Collect, read, and interpret medical documentation to ensure compliance with insurer reimbursement guidelines and proper charge capture. Act as primary contact with physicians/physician offices to obtain required documentation. Educate providers on pre‑certification protocols and maintain ongoing rapport. Communicate information to Patient Access, Case Management, and other internal stakeholders regarding contract guidelines and requirements. Research denials or problematic accounts, identify trends, and recommend process improvements. Education and Work Experience High School Diploma or equivalent. 3–5 years of pharmacy experience (clinical, hospital, outpatient, or specialty).

Licenses and Certifications: Pharmacy Technician – Tennessee Board of Pharmacy. Certified Pharmacy Technician – Pharmacy Technician Certification Board (required).

Preferred: Certified Pharmacy Technician – ExCPT (National Healthcareer Association).

Preferred: Pharmacy Technician – Mississippi Board of Pharmacy.

Knowledge, Skills & Abilities: Basic understanding of prescription processing flow. Expertise in utilizing EMRs to document clinical criteria for third‑party approval. Knowledge of medical terminology, drug nomenclature, symbols, and abbreviations in pharmacy practice. Strong attention to detail and critical thinking skills. Effective verbal and written communication with patients, associates, and health professionals. Ability to diagnose situations and recommend resolution strategies. Experience with computerized healthcare information systems. Proficiency with Microsoft Word. Supervision No supervisory responsibilities are assigned to this position.

Physical Demands: Physical activities may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion. The position requires good balance, coordination, and visual acuity. Light work involves lifting up to 25lbs occasionally or up to 10lbs frequently. The work is performed in general office or administrative settings without substantial exposure to adverse environmental conditions.