Clinical Review Operations Senior Professional

Job Summary

The Senior Clinical Operations Technician is responsible for processing, communicating, documenting and tracking complex requests for formulary exceptions, prior authorizations, quantity exceptions and brand override for delegated utilization management (UM) products and services. This role serves as a technical resource related to client specific processes and complex case research.

Responsibilities

• Serve as a point of contact for internal reviewers by providing process guidance, floor support, and assistance with case-specific questions, escalations, and complex scenarios, including peer-to-peer and independent review activities, ensuring alignment with clinical, operational, and plan requirements
• Respond to escalated calls from the Contact Center and providers, coordinating accurate information, external appeal considerations, and appropriate resolutions while ensuring thorough documentation to support correct approvals or denials
• Review clinical criteria to determine approval eligibility; enter and update prior authorizations, approvals, or denials in claims and UM systems, including reopens and edits driven by errors, client requests, or new evidence, to ensure accurate adjudication and documentation
• Monitor and manage assigned inboxes and work queues across multiple functional areas, taking timely action to meet client-specific turnaround requirements, resolve complex cases, and support accurate processing through research, documentation, and collaboration with onshore and offshore teams
• Conduct outreach to pharmacies and physician offices across multiple clients to obtain required information for UM requests, including specialty medication support, paper claim follow-up, and occasional member assistance or oral notification of final determinations to members or providers
• Provide complete and relevant clinical information related to UM requests to Pharmacists and Physicians to support clinical decision-making, peer review discussions, and independent review determinations
• Other duties as assigned

Minimum Qualifications

• High school diploma from an accredited school or equivalent GED
• 2 year of pharmacy experience or health care delivery experience

Must be eligible to work in the United States without the need for work visa or residency sponsorship

Additional Qualifications

• Strong attention to detail, accuracy, and quality; ability to adapt and work collaboratively in a dynamic fast-paced production environment
• Ability to learn internal systems/processes/programs
• Ability to work a flexible schedule to accommodate business needs including weekend shifts and holidays
• Basic math skills and general PC knowledge including Microsoft Office, Internet, and email
• Strong communication skills with focus on professional demeanor, empathy and problem-solving skills
• Action oriented with ability to act independently to resolve issues

Preferred Qualifications

• Associates degree
• National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
• 1 year of PBM experience
• Previous customer service experience

Compliance

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job.