Pharmacy Prior Authorization Specialist
9 hours ago
We are seeking a highly skilled Pharmacy Prior Authorization Technician to join our team at PSG Global Solutions Careers. As a Pharmacy Prior Authorization Technician, you will play a critical role in ensuring that our clients receive timely and accurate prior authorization decisions.
Key Responsibilities- Conduct initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the members benefit.
- Route cases directly to the pharmacist/medical director for final determination, as directed.
- Issue verbal and written member notification as required.
- Review and interpret prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of prior authorization review is required.
- Document any relevant medication history and missing information to assist the pharmacist/nurse/physician in the review process.
- Develop and implement process improvement to increase efficiency in the review process for the clinical staff.
- Work with requesting providers, clinical pharmacists, and other internal staff, as appropriate, in determining whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy and specific coverage criteria.
- Point out nuances that may not be readily apparent regarding the request.
- Contact pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed through the point-of-sale system and/or medical claim system in order to optimize the member experience.
- Act as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy and/or medical claims with prior authorization information on file or needed for the member.
- Assure appropriate authorized entry across all lines of business.
- Ensure care management system interfaces to claim processing system for claim payment.
- Perform system testing as required for upgrades and enhancements to the care management system.
- Act as a content expert for prior authorization intake for our customers, both internal and external.
- Serve as department subject matter expert for pharmacy and medical drug authorizations and coverage.
- Serve as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems to troubleshoot.
- Triage issues to the appropriate department for resolution.
- Triage prior authorization workflow daily by rerouting cases, alerting clinical staff of time frame deadlines, monitoring work queues and keeping management aware of issues related to compliance mandated time frames for review completion.
- Provide phone coverage for incoming calls as required to support the UM process. This may include authorization inquiries and information requests, claim inquiries, and other related inquiries.
- Provide friendly, accurate and timely assistance.
- Support medical and pharmacy drug pricing questions, and use drug lookup tools such as government sites, and other online resources.
- Maintain thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage and assisting other staff with related inquiries.
- Perform unit specific workflow processes consistent with corporate medical & administrative policies, employer specific guidelines, and/or regulatory agencies.
- Produce, record, or distribute information for others. On a periodic basis, track and report department performance against benchmarks.
- Prepare and assist in handling correspondence. Assure accuracy and timeliness of processing.
- Participate in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services examples include Utilization Management, Quality Management and Case Management.
- Produce, at minimum, the team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the members benefit.
- Consistently demonstrate high standards of integrity by supporting the company's mission and values, adhering to the Corporate Code of Conduct, and leading to the company's values and beliefs.
- Maintain high regard for member privacy in accordance with the corporate privacy policies and procedures.
- Perform other functions as assigned by management.
- High school diploma
- 2 years experience in health-related field is required (Associates degree preferred)
- Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred
- Ability to work prolonged periods sitting at a workstation and working on a computer
- Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time
- Typical office environment including fluorescent lighting
- Ability to work in a home office for continuous periods of time for business continuity
- Ability to travel across the Health Plan service region for meetings and/or trainings as needed
- Ability to hear, understand and speak clearly while using a phone, with or without a headset
We offer a competitive salary and benefits package, as well as opportunities for professional growth and development. If you are a motivated and detail-oriented individual who is passionate about delivering exceptional customer service, we encourage you to apply for this exciting opportunity.
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