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Pharmacy Prior Authorization Specialist - April 2026 Start Date

Primary Health Solutions
Hamilton, OH
Description

Pharmacy Prior Authorization Specialist

Department: Quality Department

Reports to: Director of Pharmacy

FLSA Classification: Non-Exempt

About Primary Health Solutions

Our Mission

We meet people where they are and partner with them on their journey towards wellness.

Our Vision

The destination for servant leaders to provide comprehensive and exceptional care.

Our Values

R – Respect

I – Innovation

S – Stewardship

E – Excellence

Pharmacy Prior Authorization Specialist Summary The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical information from electronic medical record, and timely communication with patients, prescribers and provider office staff. Candidates should possess knowledge of third-party reimbursement regulations and medical terminology as well as seek out assistance from a pharmacist as necessary. Success in this role will require strong communication, interpersonal, and problem-solving skills. This person should be able to interact and communicate effectively with internal and external customers, pharmacists, office staff, and all members of the organization.

A Day in the Life

  • Complete and submit prior authorizations for patients receiving medications prescribed by a Primary Health Solutions providers using Cover My Meds, and NextGen to ensure accurate information is being submitted.?
  • Evaluates insurance coverage and pharmacy benefits to determine patient’s ability to pay for medications and identifies the need for additional coverage options such as copay cards based on the outcome of Prior Authorizations.?
  • Maintains patient specific paper and/or electronic files to document all contact, correspondence, verification, and reason for denial for future reference through NextGen encounters.?
  • Acts as a liaison between clinical and pharmacy teams and facilitates the triaging of patient needs.??
  • Review prior authorization denials for appeal opportunities. Write and complete the appeal process in collaboration with the Primary Health Solutions pharmacy team.?
  • Assists in the management of specialty medications in collaboration with our community partners.?
  • Drive prescription volume to our in-house pharmacies where appropriate for patient’s benefit?
  • Develop process improvements for expanding the prior authorization process and data collection.?
  • Maintains effective communication and cooperative working relationships with other departments, pharmaceutical companies, members of medical and support staff, patients, and visitors.?
  • Performs all other duties and tasks as assigned.

Supervisory Responsibilities None

Core Competencies

  • Customer Service: Committed to increasing customer satisfaction, sets proper customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met.
  • Communication: Understand and communicate effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.
  • Dependability: Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.
  • Quality: Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.
  • Productivity: Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, and handles information flow.

Requirements

Success Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience

  • Certified Pharmacy Technician (CPhT) required. Proficiency in pharmacy practice.
  • Prior Authorization and/or Specialty Pharmacy experience preferred.
  • Minimum of 3 years’ experience working as a Pharmacy Technician required.??
  • Operate standard office equipment.
  • Maintains the security and confidentiality of data and information use in the performance of his/her daily duties conforming to health center policy, laws, and regulations as appropriate.?
  • Handles telephone inquiries, and email referrals.?
  • General knowledge of medical and pharmacy insurance plans, reimbursement and government regulations.?
  • Developed knowledge of Microsoft Word and Excel?
  • Self motivation and organizational skills?
  • Developed knowledge of medications and medical terminology

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills

To perform this job successfully, an individual should have the ability to gain knowledge of current electronic medical record, Intranet, Microsoft Word, Excel, PowerPoint, and Outlook.

Certificates, Licenses, Registrations

Certified Pharmacy Technician (CPhT) required. Proficiency in pharmacy practice.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. 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 frequently required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to sit and stoop, kneel, crouch, or crawl. The employee must regularly lift and /or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee are occasionally exposed to fumes or airborne particles; toxic or caustic chemicals and risk of radiation. The noise level in the work environment is usually moderate.

While the position will work in a normal office environment, some travel to the local pharmacies and community partner locations will be necessary. Regular and predictable on-site attendance is required for this position.?

Affirmative Action/EEO Statement

It is the policy of Primary Health Solutions to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Posted 2026-01-23

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