Manager Prior Authorization Jobs in Raleigh, NC (NOW HIRING)

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.

Job Posting Title

Clinical Pharmacy Technician Sr - Medi-Cal Rx

Job Description

The Senior Clinical Pharmacy Technician - Medi-Cal independently manages prior authorization requests, eligibility, pharmacy benefits, and claims using established clinical criteria. This role serves as a technical resource to team members, supports resolution of non-routine cases, and identifies opportunities to improve workflow efficiency.

Responsibilities

• Independently review, research, and resolve prior authorization requests by applying clinical criteria, established guidelines, and professional judgment within defined protocols

• Communicate coverage determinations, formulary alternatives, and prior authorization requirements to providers and internal stakeholders, ensuring clarity and accuracy in non-routine scenarios

• Manage inbound and outbound inquiries related to eligibility, benefits, claims, and prior authorizations, resolving moderately complex issues and determining appropriate next steps

• Escalate clinically complex or exception-based cases to a pharmacist, providing thorough documentation and relevant case context to support timely resolution

• Educate providers and members on claims submission processes, appeals requirements, and reimbursement guidelines across multiple networks

• Initiates, prioritize, and manage cases by accurately gathering and entering member and provider information

• Identify trends, root causes, high-risk inquiries, and workflow gaps in daily operations and recommend process improvements to enhance efficiency, quality, and consistency

• Serve as a resource to team members by providing guidance, answering process questions, and supporting onboarding activities

• Other duties as assigned

Minimum Qualifications

• High school diploma from an accredited school or equivalent GED

• 2 years of work experience as a pharmacy technician

• Licensed Pharmacy Technician in accordance with California state requirements

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

Additional Qualifications

• Strong knowledge of pharmacy workflows, terminology, and reimbursement processes

• Ability to prioritize work and manage multiple assignments in a dynamic environment

• Effective communication skills with the ability to guide and support team members

• Proficiency in pharmacy systems and Microsoft Office applications

Preferred Qualifications

• 1 year reimbursement experience

• PBM or health care experience

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

To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (https://www.primetherapeutics.com/benefits) and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits).

Prime Therapeutics LLC?is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. ?

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.

At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference.

We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together.

Prime Therapeutics LLC?is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to?race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. ?? ?

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at email Careers@primetherapeutics.com.