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We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
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.As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of NeueHealth, our consumers, and the communities we serve.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
