Prior Authorziation Specialist

This position reports to the Director, Clinical Pharmacy Programs. The Prior Authorization (PA) Specialist supports the clinical team by initiating, processing, and tracking medication prior authorization (PA) requests to help ensure timely access to therapy. This role gathers and verifies required clinical documentation, communicates with prescribers, payers, and internal stakeholders, and maintains accurate records in pharmacy systems and payer portals. Central to this position is the ability to follow clinical guidelines, think independently, and render decisions as directed by Clinical leadership. The position requires consistent attention to HIPAA compliance, detail, and turnaround times.

Prior Authorization Intake & Processing

• Initiate and process medication prior authorization (PA) requests in accordance with payer requirements and internal workflows.
• Gather, verify, and submit required clinical/administrative documentation (e.g., chart notes, lab values, medication history) via payer portals, fax, or phone.
• Accurately enter and maintain PA status updates in pharmacy systems and tracking tools; monitor turnaround times and follow up as needed.
• When a PA is denied, review denial communications for missing information and required appeal components and initiate retrieval of supporting documentation.
• Request and obtain additional clinical documentation from medical providers as needed to support PA and appeal submissions (e.g., chart notes, lab results, diagnosis confirmation).

Payer, Prescriber, and Patient/Member Communication

• Serve as a point of contact to communicate PA requirements, status updates, and next steps with prescriber offices and payer representatives.
• Obtain missing information needed to support PA decisions and coordinate timely responses to payer requests for additional documentation.
• Conduct outbound calls to medical providers, patients/members, and pharmacies to confirm continuity of care for new members and to verify current therapy, prescribing information, and dispensing details; document outreach attempts, contacts, and outcomes in the appropriate tracking system.
• Coordinate appeal submission logistics by confirming payer requirements, routing appeal packets for pharmacist sign-off, submitting to the payer upon approval, and following up to verify receipt and status.
• Escalate clinical questions, denials, or urgent access issues to the Clinical Pharmacist III or appropriate clinical staff.

Documentation, Compliance & Quality

• Maintain complete, accurate, and timely documentation of all PA activity in accordance with company policies and payer requirements.
• Ensure all work is performed in a HIPAA-compliant manner, protecting confidential and protected health information (PHI) during all communications and data entry.
• Identify trends, recurring issues, or process gaps and communicate opportunities for workflow improvement to the clinical team.
• Audit claims, authorizations, and the prior authorization queue to confirm items are complete and accurately documented  
• Identify discrepancies and coordinate resolution with appropriate stakeholders.

Administrative Support & Reporting

• Track and report PA workload, outcomes (approved/denied), and turnaround times as requested using Microsoft Excel and other tools.
• Prepare denial/appeal workups for Clinical Pharmacist III review by compiling the denial rationale, payer criteria, key dates/deadlines, and relevant clinical/supporting documentation; draft appeal cover sheets or templates as applicable per workflow. 
• Draft, update, and maintain standardized letter templates to support PA/appeal and information requests, ensuring templates capture and auto-populate pertinent details per workflow. 
• Support audit readiness by maintaining organized electronic records and retrieving documentation upon request.
• Participate in training, meetings, and process updates to maintain knowledge of payer rules and internal procedures.

Other 

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data. 
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit). 
• Maintain a current California Board of Pharmacy Technician license.
• All other duties as assigned. 

The physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.

• High school diploma or equivalent and minimum of five (5) years of retail pharmacy experience and/or PBM experience; prior authorization experience preferred.
• Current California Board of Pharmacy, Pharmacy Technician license (required).
• Proficiency with pharmacy systems and documentation; experience using insurer portals and phone/fax communication; strong Microsoft Office skills (Excel and Word).
• Ability to understand and apply clinical criteria to requests for coverage at all times.
• Must be highly organized and detail oriented.
• Experienced in provider outreach and gathering relevant clinical information.
• Able to interact efficiently and effectively with internal and external customers.
• Excellent written and oral communication skills, and interpersonal skills.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.