Prior Authorization Specialist

Prior Authorization Specialist

Full-Time | On-Site | Clifton, NJ

Middle Village Pharmacy is hiring a full-time, on-site Prior Authorization Specialist at our Clifton, NJ location. You'll be the person who gets patients' medications and services approved by insurers and PBMs quickly and correctly. You'll submit and track prior authorizations, handle denials and appeals, verify benefits, and keep patients and prescribers updated so no one is left waiting on therapy.

At a Glance

Position: Prior Authorization Specialist

Location: On-site, Clifton, NJ (Passaic County)

Employment type: Full-time, non-exempt (hourly)

Schedule: Monday–Friday, about 8:30 AM–5:00 PM (40 hours/week); occasional coverage as business needs require

Pay: $22.00–$28.00 per hour (about $45,800–$58,200 per year), based on experience, certifications, and skills

Benefits: 401(k) and 1 week of paid time off (PTO) after one year of employment

What You'll Do

Find and work prior authorization requests from rejected pharmacy claims (e.g., NCPDP reject 75), prescriber requests, and work queues

Prepare and submit electronic PAs through CoverMyMeds, Surescripts/ePA, and payer/PBM portals, plus fax and phone submissions when needed

Collect the required clinical documentation from prescriber offices (diagnosis/ICD-10 codes, chart notes, labs, prior therapies tried and failed) and complete payer-specific criteria forms accurately

Follow up on pending requests until resolved, keep a PA tracking log, and meet payer and internal turnaround times, including expedited/urgent requests

Handle denials: identify the reason, coordinate letters of medical necessity, formulary or tier exceptions, step-therapy exceptions, peer-to-peer reviews, and first- and second-level appeals

Run benefits investigations and eligibility checks: pharmacy vs. medical benefit, coverage, copays and deductibles, quantity limits, and specialty pharmacy requirements

Help patients find affordability options when coverage is limited (manufacturer copay cards, patient assistance programs, and foundations)

Communicate clearly with patients, prescribers, pharmacists, and insurers about PA status, approvals, and next steps

Document every action accurately in the pharmacy management system/EHR, maintain HIPAA compliance, and protect patient information

Track trends in denials and payer requirements and share updates with the team to improve first-pass approval rates

Must-Have Qualifications

Bachelor's degree required, preferably in Healthcare Administration

1+ year of hands-on prior authorization experience in a pharmacy, specialty pharmacy, PBM, physician practice, or hospital setting

Working knowledge of commercial plans, Medicare Part D, and NJ Medicaid/NJ FamilyCare managed care plans, plus how PBMs process claims

Experience with CoverMyMeds and/or major payer and PBM portals

Understanding of medical and pharmacy terminology, ICD-10 codes, and common drug names

Strong attention to detail, organization, and follow-through, with the ability to manage a high volume of open cases

Professional phone and written communication skills

Comfort with computers: pharmacy or EHR systems, Microsoft Office/Google Workspace, and fast, accurate data entry

Nice-to-Have Qualifications

Active New Jersey Pharmacy Technician registration and/or national certification (CPhT through PTCB or ExCPT through NHA)

Billing or coding certification (e.g., CPC, CPB, CBCS, CRCS)

Specialty pharmacy experience (biologics, oncology, HIV, hepatitis C, GLP-1s, injectables) or medical-benefit PAs (buy-and-bill, J-codes)

Experience with pharmacy management systems (e.g., PioneerRx, PrimeRx, Liberty, QS/1, BestRx) or EHRs (e.g., Epic, eClinicalWorks, athenahealth)

Experience with appeals, peer-to-peer coordination, and patient assistance or copay programs

Bilingual (English/Spanish or another language common in Passaic County) is a strong plus

What Success Looks Like

PAs are submitted promptly and completely, with few avoidable denials

No request goes stale: every open case has a documented next step and follow-up date

Patients and prescribers always know where their request stands

How to Apply

Send your resume and a short note describing your prior authorization experience (settings, systems, and typical daily volume) to [email protected] with the subject line "Prior Authorization Specialist – Clifton". Qualified candidates will be contacted for a brief phone screen, followed by an on-site interview in Clifton.

Middle Village Pharmacy is an equal opportunity employer. We consider all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other characteristic protected by law.

Pay: $22.00 - $28.00 per hour

Benefits:

• 401(k)
• Paid time off

Work Location: In person