Job Description

Job Description

Job Description

Job Description

This role focuses on reviewing pharmacy prior authorization requests within a pharmacy services department for a large health insurance organization. You will evaluate coverage determination requests for a wide range of medications and health plans, approve or deny requests based on established criteria, and route them to a pharmacist for final review. The position involves working in multiple systems, documenting decisions accurately, and occasionally handling inbound member calls in a professional remote environment.

Responsibilities

• Review prior authorization and coverage determination requests submitted by providers for a broad range of medications and health plans.
• Determine whether a pharmacist review is required and route requests accordingly for final clinical review.
• Approve coverage determination requests based on clearly defined criteria and established guidelines.
• Deny requests when criteria are not met and ensure appropriate routing to a pharmacist for final review.
• Enter and document all coverage determination decisions accurately in the pharmacy benefit management (PBM) system.
• Notify providers and/or members of coverage determination decisions in a clear and timely manner.
• Track and monitor coverage determination requests to ensure timely processing and follow-up.
• Obtain verbal authorizations and request detailed clinical information from prescribers when needed.
• Contact providers to gather additional information required to complete coverage determination reviews.
• Respond to client inquiries regarding authorization approvals and PBM online applications.
• Refer coverage determination requests for specialty medications to the appropriate delegated vendor or client for processing.
• Handle a small volume of inbound phone calls from members and providers in a professional and customer-focused manner.
• Collaborate with pharmacists and other team members to support accurate and efficient prior authorization workflows.
• Maintain accurate records and documentation in all relevant systems while working across multiple screens and applications.
• Uphold all regulatory, compliance, and internal policy requirements related to prescription benefits and pharmacy operations.

Essential Skills

• Current registration as a pharmacy technician in the state of residence.
• National certification as a pharmacy technician (such as CPhT or NHA).
• High school diploma or GED.
• Demonstrated strong computer skills, including the ability to work efficiently in multiple systems and across multiple screens.
• Basic proficiency with Microsoft Office applications, including Outlook.
• Ability to accurately enter and document information in a PBM system or similar healthcare software.
• Customer service skills with the ability to communicate clearly with providers, prescribers, and members.
• Ability to review clinical and coverage information and apply defined criteria to make coverage determinations.
• Capability to work in a structured, metric-driven environment with attention to accuracy and timeliness.
• Reliable access to strong Wi-Fi and the ability to work independently in a dedicated home office space.

Work Environment

This is a fully remote, professional pharmacy services position in a large healthcare organization. You will work from your own dedicated home office space with a closed door and reliable high-speed Wi-Fi. The company provides all necessary equipment, including a computer, monitor, and headset. Training runs on an approximate 10:00 a.m. to 6:30 p.m. Eastern Time schedule. After training, your regular schedule will be set in your local time zone within operating hours of Monday through Friday, 7:00 a.m. to 8:00 p.m., with participation in a rotating weekend schedule approximately every 4 to 6 weeks. You must also be able to work some holidays, with holiday schedules assigned through a bidding process. Overtime is not required but may be offered periodically. The environment is technology-driven, with work performed across multiple screens and systems, and communication primarily via online platforms and phone. A smart phone is required for certain security or communication needs. The dress code is appropriate for a professional remote work setting during any video or live interactions.

This is a Contract to Hire position based out of Fort Worth, TX.

The pay range for this position is $20.00 - $24.00/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave)

This is a fully remote position.

This position is anticipated to close on Oct 12, 2026.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service.

The company is an equal opportunity employer and will consider all applications withoutregard to race, sex, age, color, religion, national origin, veteran status, disability,sexual orientation, gender identity, genetic information or any characteristic protectedby law.

If you would like to request a reasonable accommodation, such as the modification oradjustment of the job application process or interviewing process due to a disability,please email actalentaccommodation@actalentservices.com for other accommodation options.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in thecity and county of San Francisco, we will consider for employment qualified applicantswith arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as acondition of employment or continued employment. An employer who violates this lawshall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process,including sourcing, screening, and evaluating candidates. AI helps assess applicationsand qualifications, but final decisions are made by our hiring team. By applying, youacknowledge and agree that your application may be reviewed using AI tools.

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