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Prior Authorization Specialist
1 month ago
US Tech Solutions - Prior Authorization Specialist – MED D Please note: Actual location may vary, Rhode Island. The Prior Authorization Specialist takes inbound calls from providers, pharmacies, members, etc., providing professional and courteous phone assistance to all callers through the criteria-based prior authorization process. Responsibilities include maintaining complete, timely, and accurate documentation of reviews, transferring all clinical questions, escalations, and judgment calls to the pharmacist team, and assisting with other duties as needed, including outbound calls, reviewing and processing prior authorizations received via fax and ePA, and monitoring and responding to inquiries via department mailboxes. Work closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business in accordance with Medicare Part D CMS Regulations. Must apply information provided through multiple channels to the plan criteria defined through work instruction. Research and conduct outreach via phone to requesting providers to obtain additional information to process coverage requests and complete all necessary actions to close cases. Responsible for research and correction of any issues found in the overall process. Phone assistance is required to initiate and/or resolve coverage requests. Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed. Must maintain compliance at all times with CMS and department standards. Position requires schedule flexibility and additional cross-training to learn all lines of business. Responsibilities: Utilizing multiple software systems to complete Medicare appeals case reviews Meeting or exceeding government-mandated timelines Complying with turnaround time, productivity, and quality standards Conveying resolution to beneficiary or provider via direct communication and professional correspondence Acquiring and maintaining basic knowledge of relevant and changing Med D guidance Effectively manage work volume by handling inbound calls/fax/ePA requests utilizing appropriate courteous and professional behavior based upon established standards Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers Communication with other internal groups regarding determination status and results (seniors, pharmacists, appeals, etc.) Identify and elevate clinical inquiries to the pharmacist team as appropriate Experience: 0-3 years in a customer service or call center environment managing 75 calls/day Six months of PBM/pharmaceutical related work strongly desired At least two years of general business experience that includes problem resolution, business writing, quality improvement, and customer service Skills: Prior Authorization Medicare and Medicaid Education: High School diploma or GED About US Tech Solutions: US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com . US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. #J-18808-Ljbffr
