PSS - Claims & Authorization Specialist

PSS - Claims & Authorization Specialist

Position Type: Full-Time, In-Office (Nashville)

Department: Pharmacy Operations & Product Support Team

Reports To: Pharmacy Support Specialist Supervisor

Position Summary

The PSS Claims & Authorization Specialist is a highly technical operational role focused on executing workflows within specialized pharmacy systems. This individual will manage tasks inside our prior authorization platform and work directly within PBM claim processing systems to execute and troubleshoot overrides. Additionally, this role serves as the primary internal resource for escalated, sensitive, or complex member and provider concerns, ensuring comprehensive resolution and clinical team support.

Core Responsibilities

• System Operations: Manage and execute complex administrative workflows related to prior authorizations and appeals directly within the Banjo platform.
• Claims & Overrides Processing: Navigate PBM claim processing systems to enter, troubleshoot, and resolve pharmacy claim overrides.
• Clinical Team Collaboration: Provide advanced support to the clinical team during prior authorization case reviews and documentation gathering.
• Escalation Handling: Act as the designated resource for escalated, high-touch, or complex inbound member and provider concerns, ensuring end-to-end resolution and compliant documentation.
• Outbound Clinical Support: Coordinate with the clinical team to handle advanced outbound communications to prescribers, pharmacies, and members.
• Special Projects: Manage operational sub-projects, inventory tasks, or cross-functional tracking initiatives as the product line scales.

Requirements & Qualifications

• Education: High school diploma or equivalent
• Experience: Minimum of 1 year of direct experience in PBM operations is strictly required, including specific exposure to medical necessity workflows or prior authorization case reviews.
• Licensure: Pharmacy Technician experience/certification is highly preferred.
• Advanced Systems & CRM Proficiency: Confident and agile in using complex technology suites, specialized PBM processing architectures, and CRM platforms. Proven ability to seamlessly pivot between multiple system modules to input data, resolve technical claim overrides, and pull up-to-date member profiles. 
• Problem Solving: A proven track record of resolving complex customer conflicts, managing projects, and fostering collaboration across different stakeholders.
• Technical Skills: Advanced proficiency in navigating specialized PBM claim systems and platforms (e.g., Banjo), alongside strong skills in Google Work products and Microsoft Office.
• Mindset: Adaptable, fast learner who can independently navigate complex health plan guidelines and technical systems.

Qualifications and skills:

• Competitive candidates will have a minimum of 2 years experience in PBM operations, including medical necessity or prior authorization case reviews 
• Candidates without PBM experience will be considered if they have leadership experience, e.g. team lead or trainer, or experience with special projects, e.g. inventory management
• Fast learner and interested in potential growth opportunities as the product roles expand
• Excellent verbal and written communication skills a must
• Pharmacy technician experience preferred
• PBM experience preferred
• A track record of fostering collaboration, resolving conflicts, and managing projects is preferred.
• Excellent technical skills in Google Work products (Docs, Drive, Slides) and Microsoft (Word, PPT, Excel)

Company Standard Requirements:

• Ability to work well with others in a collaborative environment
• Ability to get things done with resources you don’t control
• Willingness to admit you don’t know and ask for help
• Exhibit constant curiosity and a drive to problem solve
• Exhibit desire to learn and grow on a continuous basis