Prior Authorization Specialist I

POSITION Summary:

The Prior Authorization Specialist is responsible for tracking the client’s prior authorization status through completion. This role will accurately process the requests according to regulatory and client-specific guidelines. This position reports to the Prior Authorization Supervisor.

Note: This position will initially be in-office 5 days a week during normal business hours. After training and initial ramp-up period, eligibility for a hybrid work schedule with 3 required in-office days per week may be granted.

KEY RESPONSIBILITIES

• Makes outbound calls to Insurance Payers and/or Specialty Pharmacies to obtain patient benefits and authorization information
• Understands and completes Prior Authorization calls within the In Process queue
• Completes call sheets completely and accurately
• Understands and adheres to the eBlu Guarantee of a turnaround time of 8 hours for Sponsored Drugs
• Process documents based on department guidelines per standards and performance indicators.
• Maintain the highest level of patient confidentiality.
• Recognizes group discrepancies and escalates when needed
• Utilizes all resources and tools i.e., Payer Notes, Google, Caller Guide, etc
• Provide the highest level of customer service when representing eBlu
• Actively listens to calls in Ring Central to identify training opportunities or to gather important information from the call
• Accurately interprets notes on the call sheet provided by the senior or Supervisor prior to outreach
• Provides prompt communication to Supervisor for updated Payer information
• Understanding of the Availity chat to Save and upload to Microsoft Teams Channels as needed
• Ability to investigate call sheets in Review Completed status
• Active participation in 1:1s with Supervisor
• Provides 24 hours' notice for any personal time off
• Review updates and changes communicated in Microsoft Teams chats and respond/react to the message
• Can manage day-to-day responsibilities independently with the support of the Supervisor as needed
• Track and manage the authorization process
• Respond to and resolve all internal and external inquiries in a timely, accurate, and complete manner.
• Process authorizations based on department guidelines and in accordance with standards and performance indicators
• Manage prior authorization activity queues related to position
• Provides timely communication throughout the prior authorization process
• Understands and adheres to the eBlu Guarantee of a turnaround time of 8 hours for Sponsored Drugs
• May be trained in Initiating authorizations to Payers via portal, fax or phone
• May need to provide continued follow up for cases submitted by eBlu or provider in accordance with the SOP
• Measured monthly, meets the minimum expectation of 14 call sheets per day
• Maintains a quality score of 98% or higher
• Can manage day-to-day responsibilities independently with the support of the Supervisor as needed
• Other duties and responsibilities as assigned by the supervisor based on the specific client contract.

EXPERIENCE, SKILLS & QUALIFICATIONS

EDUCATION

• High School Diploma or GED required
• Bachelor's degree preferred or equivalent work experience

EXPERIENCE

• 3-5 years’ experience in a health plan, facility, healthcare provider office, or pharmaceutical industry required
• Experience working with insurance companies and extensive knowledge of different types of coverage and policies required
• Experience with pre-certification or pre-authorization required
• 3-5 years’ experience in a call center preferred
• Knowledge of medical terminology preferred
• Working knowledge of drug reimbursement issues preferred
• Understanding of health plan medical policies and prior authorization criteria
• Knowledge of HCPCS, CPT, and ICD-10 coding

SKILLS

• Must have excellent multitasking skills to allow for success in the role
• Have exceptional attention to detail and excellent analytical, investigation, and problem-solving skills
• Must be very detail-oriented and organized to maintain accurate patient insurance records
• Ability to focus and work quickly within a 24-hour turnaround for patient insurance information.
• Strong communication and interpersonal skills.
• Ability to work and resolve issues independently and collaboratively in a team environment.
• Proactive and able to take initiative in driving projects forward.
• Ability to follow instructions
• Strong computer skills; preferably Microsoft Word or Excel software applications
• Ability to calculate figures and amounts such as discounts and percentages; necessary to provide correct benefit and co-pay information
• Ability to manage multiple priorities concurrently

PHYSICAL AND TECHNICAL ENVIRONMENT:

• Ability to work at a desk in the office for long periods of time.
• Noise level in the work environment is moderate.
• Specific vision abilities required by this job include close vision and color vision.
• Ability to maintain focus under high levels of pressure/multiple priorities.

EBLU SOLUTIONS IS AN EQUAL OPPORTUNITY EMPLOYER - eBlu Solutions seeks talent from all backgrounds to bring diversity of thought, agility, and capability to our organization. We promote a working environment where all employees are treated and rewarded fairly. We do not tolerate any form of discrimination that adversely affects individuals or groups based on national origin, race, color, religion, sex, gender, sexual orientation, marital status, disability, age, or any other legally protected aspect of a person’s identity.