Pharmacy Prior Authorization Specialist

6 days ago

Waltham, Massachusetts, United States Onco360 Full time

We are seeking a highly skilled Pharmacy Prior Authorization Specialist to join our team at Onco360 Pharmacy. As a Pharmacy Prior Authorization Specialist, you will play a critical role in ensuring that patients receive the medication they need by receiving prescriptions, addressing and rectifying rejected claims, and conducting necessary third-party authorization requests.

Primary Responsibilities:

  • Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
  • Follow prior authorization workflow and policies and procedures.
  • Collaborate with other departments to assist in obtaining prior authorizations.
  • Review accuracy and completeness of information requested and ensure that all supporting documents are present.
  • Receive requests for prior authorizations and ensure that they are properly and closely monitored.
  • Consult with supervisor or pharmacist to obtain clearance that treatment regimen is appropriate.
  • Process referrals and submit clinical supporting documentation to insurance carriers to expedite prior authorization processes.
  • Manage correspondence with insurance companies, physicians, and patients as required.
  • Look through denials and submit appeals if requested by physician to get them approved from insurance companies.
  • Document all prior authorization information, including approval dates and prior authorization numbers, in patient profiles.
  • Proactively work on prior authorizations that are due to be expired.
  • Secure patients' demographics and medical information by using great discretion and ensuring that all procedures are in sync with HIPAA compliance and regulations.

Qualifications:

  • Good interpersonal skills.
  • Excellent verbal, written, and customer service skills.
  • Ability to work independently, meet deadlines, and be flexible.
  • Good organizational skills and attention to detail.
  • Knowledge of medical terminology, including sig codes and Roman numerals, brand and generic names of medications, and general pharmacy terminology.
  • Ability to perform tasks accurately and efficiently when inputting information.
  • Licensed or registered pharmacy technician or as required by state law.
  • Basic math and analytical skills.
  • Intermediate typing and keyboarding skills.

Requirements:

  • High School Diploma or GED.
  • Previous experience in pharmacy and prior authorizations.

Desired:

  • Associate degree or equivalent program from a 2-year program or technical school.
  • Certified Pharmacy Technician (PTCB).
  • Specialty pharmacy experience.

Skills/Knowledge:

  • Prior authorization process.
  • CoverMyMeds experience.
  • Knowledge or understanding of pharmacy insurance claims, Medicare, Medicaid, and commercial insurance.
  • Pharmacy test claim and NCPDP claim rejection resolution.
  • Coordination of benefits.
  • NDC medication billing.
  • Pharmacy or healthcare-related knowledge.
  • Knowledge of pharmacy terminology, including sig codes and Roman numerals, brand and generic names of medications.
  • Basic math and analytical skills.
  • Intermediate typing and keyboarding skills.

Licenses/Certifications:

  • Registration with the Board of Pharmacy as required by state law.

Behavior Competencies:

  • Independent worker.
  • Good interpersonal skills.
  • Excellent verbal and written communication skills.
  • Ability to work independently, work efficiently to meet deadlines, and be flexible.
  • Detail-oriented.
  • Great time-management skills.

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