Clinical Prior Authorization Technician

Prepare prior authorization requests received by validating prescriber and member information, level of review, and appropriate clinical guidelines. Make outbound calls to providers to obtain additional clinical information to ensure substantial clinical information exists to reach a clinical determination for pharmacist review. Proactively obtains clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review. Review and analyze pharmacy claims data for proactive outreach and intervention. Identify, document, and escalate provider concerns to the appropriate internal team including various members of the Prior Authorization Team. Triage phone calls from members, pharmacy personnel, and providers by asking applicable drug and client specific clinical questions. Effectively communicate issues and resolutions to members, pharmacy staff, providers, and appropriate internal stakeholders. Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies