UM Pharmacy Technician

Job Summary:
The UM Pharmacy Technician is responsible for processing prior authorization requests to ensure pharmacy benefits are used efficiently, aligning with clinical guidelines, regulatory standards, and cost-containment strategies. This role involves collaboration with healthcare providers, pharmacy benefit managers (PBMs), and internal teams to optimize medication therapy, minimize unnecessary expenses, and enhance patient outcomes.

Key Responsibilities:

Utilization Review & Prior Authorization:

• Evaluate prior authorization (PA) requests and provide recommendations based on evidence-based criteria.
• Communicate with healthcare providers to gather required clinical information.
• Document review outcomes in electronic records and notify members and providers of approvals or denials as per department procedures.
• Identify and flag potential medication overuse or inappropriate medication orders.

Clinical Evaluation & Compliance:

• Assess drug utilization for safety, efficacy, and cost-effectiveness.
• Ensure adherence to state and federal regulations, including Medicare, Medicaid, and health plan payer guidelines.
• Monitor for potential fraud, waste, and abuse in medication use.

Provider & Member Support:

• Collaborate with prescribers to suggest alternative, cost-effective therapies when appropriate.
• Educate providers on formulary options, step therapy protocols, and best prescribing practices.

Interdepartmental Collaboration:

• Work closely with PBMs, case managers, and medical management teams to support integrated patient care.
• Contribute to quality improvement initiatives related to pharmacy utilization management.

Qualifications & Skills:

• Education: High school diploma or equivalent required
• Licensure: Certified Pharmacy Technician (CPhT) preferred.
• Experience:
  • 1-3 years of experience in pharmacy utilization management, managed care, or clinical pharmacy practice.
  • Experience with prior authorization reviews, health plan pharmacy services, and PBMs.
• Knowledge & Competencies:
  • Understanding of CMS regulations, Medicaid/Medicare drug coverage policies, and NCQA/URAC accreditation standards.
  • Proficiency in electronic health records (EHRs), prior authorization systems, and Microsoft Office applications.
  • Strong analytical, problem-solving, and communication skills.

For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $27.10-$40.65 Hourly.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.