Prior Authorization Specialist (Pharmacy)

Shift: Mon-Fri (8:30am-5pm), ONSITE

Location: Plano, TX (75024)

The Authorization Support Specialist plays a critical role in supporting the Prior Authorization (PA) workflow by ensuring timely follow-up, accurate documentation, and effective communication with insurance payers and internal clinical teams. This position is responsible for managing the full prior authorization lifecycle, including submission of prior authorization requests, payer follow-up, interpretation of payer responses and reject codes, documentation of approvals and denials, and coordination with clinical and operational teams.

Other duties may be assigned as necessary.

• Prior Authorization Submission & Processing: Prepare and submit prior authorization requests through payer portals, fax, phone, or electronic systems, ensuring all required clinical and insurance documentation is included and submitted accurately and timely.
• Prior Authorization Status Follow-Up: Proactively contact insurance companies via phone, portals, or fax to obtain real-time status updates on submitted prior authorization requests and resolve pending issues to prevent delays in patient therapy.
• Reject Code Review & Resolution: Interpret and work insurance reject codes, payer edits, and claim rejections to identify root causes, determine required next steps, and coordinate appropriate resolution or escalation.
• Documentation & Data Entry: Accurately enter PA approval letters, authorization numbers, effective dates, denial documentation, and payer communications into CareTend and other applicable systems.
• Denial Review & Routing: Review PA denial letters for completeness and clarity, ensuring all required documentation is captured before forwarding cases to the Clinical Utilization Team for clinical review and appeal determination.
• Queue & Workflow Management: Monitor assigned PA work queues to ensure timely follow-up, proper prioritization, and prevention of delays in therapy initiation or continuation.
• Payer Communication & Tracking: Maintain detailed and accurate notes of payer interactions, including call outcomes, reference numbers, authorization status, reject details, and next steps in accordance with internal documentation standards.

Requirements:

• Must have at least 2 years of direct experience managing the full prior authorization life cycle for a retail or specialty pharmacye
• Pharmacy Technician license is preferred
• Strong data entry accuracy
• Knowledge of pharmacy abbreviations (SIG codes)
• Familiarity with brand and generic medications

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.