Medication Prior Authorization Specialist - Immediate Start

Under general supervision, the prior authorization/insurance resource specialist will be responsible for processing prior authorization requests to obtain prescription approval. This role is also responsible for various other functions as described below.

ESSENTIAL FUNCTIONS (ROLES AND RESPONSIBILITIES):

• Collect and analyze supporting clinical documentation as appropriate for the prescription requested. Identify and initiate the processing of any missing clinical data such as labs, testing, medical records, etc.
• Submit prior authorization documents to the insurance company via preferred methods such as phone, fax or third party websites. Call insurance company directly to verify eligibility as needed.
• Communicate directly with insurance companies, providers, pharmacies and patients regarding prior authorizations status. Document all communications in EMR (Centricity).
• Constant daily monitoring, organizing and review of multiple desktops within the EMR as well as other required computer applications. Ex. Cover my meds, Faxcom.
• Assist in completing prescription refills in Centricity and Faxcom.
• Provide explanation to patient’s regarding insurance deductibles, copays, coverage gaps as it applies to their prescription coverage.
• Provide and assist patients with resources to apply for patient assistance programs where eligible. Ex. Medicare, State programs, Pharmaceutical companies, Non-profit organizations.
• Access or request medical records as required for authorization submission. Maintain access to computer applications needed for records. Ex. EPIC, Labcorp, Quest.
• Review insurance drug formularies to assist providers in selecting treatment in line to formulary selections.
• Submit appeals as appropriate with detailed, clinical response. Appeals processing may require sourcing such as peer reviewed articles or other clinically researched documentation.
• Lead team member for Leqvio/Healix processes and communications.
• Other duties as assigned.

QUALIFICATIONS/REQUIREMENTS/COMPETENCIES:

• High school diploma or GED required.
• Understanding of medical terminology is required.
• Minimum 1 year experience in prior authorization, medical assistant, pharmacy technician, LPN or similar role is required. Cardiology experience highly preferred.
• Must have excellent customer service and oral / written communication skills.
• Must be detail oriented and use critical thinking skills.
• Must be a self-motivated individual, able to work independently with minimal guidance and as part of a team.
• Must have the availability to work the required schedule, Monday-Friday 8:00 a.m. - 4:30 p.m.

WORK ENVIRONMENT:

• Regular medical office environment.
• Must have ability to walk, sit, bend, and lift up to 10 pounds.
• Must be flexible and work overtime as needed.