Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations Establishes and maintains communication among health plan, and employer group staff Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours availability as needed