Job Description

Job Title: Pharmacy Prior Authorization Specialist

Department: Clinical / Revenue Cycle

Reports To: Practice Manager / Clinical Supervisor

FLSA Status: Non-Exempt

Position Summary

The Pharmacy Prior Authorization Specialist is responsible for coordinating and managing medication prior authorizations to ensure timely access to prescribed therapies for patients. This role serves as a liaison between providers, patients, pharmacies, and insurance companies to obtain approvals, minimize delays, and support optimal patient care while ensuring compliance with payer requirements.

Essential Duties and Responsibilities

• Initiate, submit, and track prior authorization requests for prescription medications, specialty drugs, and biologics.
• Review provider documentation to ensure medical necessity criteria are met per payer guidelines.
• Communicate with insurance carriers to resolve authorization issues, denials, and requests for additional information.
• Follow up on pending authorizations and escalate urgent or time-sensitive requests.
• Notify providers and clinical staff of authorization outcomes and alternative coverage options when applicable.
• Assist with appeals, including compiling clinical documentation and supporting letters.
• Coordinate with pharmacies, specialty pharmacies, and patients regarding medication approval status.
• Maintain accurate records in the electronic health record (EHR) and practice management systems.
• Stay current on insurance formularies, payer policies, and authorization requirements.
• Assist physicians and patients in getting samples by calling established drug representatives.
• Administer injections
• Administer small bowel pill camera for capsule endoscopy patients and upload results onto disc
• Ensure compliance with HIPAA and regulatory requirements.

Required Qualifications

• High school diploma or equivalent required; associate degree or medical certification preferred.
• CCMA or CMA
• Experience with medication prior authorizations preferred.
• Knowledge of insurance plans, formularies, and pharmacy benefit processes.
• Strong attention to detail, organization, and time-management skills.
• Excellent written and verbal communication skills.
• Proficiency with EHR systems and insurance portals.

Preferred Qualifications

• Experience in a specialty medical practice.
• Familiarity with specialty medications and biologics.
• Certification as a Medical Assistant, Pharmacy Technician, or related credential.

Work Environment & Physical Requirements

This position is based in a medical office or clinic setting and requires prolonged periods of sitting, computer use, and telephone communication. Standard business hours apply, with occasional overtime as needed.