Prior Authorization Coordinator (Fully Remote)

Description

WHO WE ARE

Founded in 1983, the Medical Review Institute of America (MRIoA) is the market leader for technology-enabled utilization management and clinical medical review solutions. We have an outstanding reputation for excellence and achieve continual improvement.

At MRIoA, we believe our employees are the key to our success. Here, you are more than just a cog in the machine – you are a valued member of our team.

WE OFFER

• A competitive compensation package.
• Benefits include healthcare, vision and dental insurance, a generous 401k match, paid vacation, personal time, and holidays.
• Growth and training opportunities.
• A team atmosphere with fun events and prizes scheduled throughout the year.

Position Summary

• The Prior Authorization Coordinator processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments.
• Performs analysis, obtains information, and enters prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based on clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.).
• Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality.

Roles

• Process and finalize PA requests within clients’ turnaround time (TAT) and Performance Guarantees (PGs) utilizing guidelines. 
• Accountable for achieving prior authorization processing productivity and accuracy standards

Major Responsibilities or Assigned Duties

• Enter prior authorizations into the system and prioritize requests. 
• Check formulary alternatives and review tried and failed medications. 
• Utilize drug references and verify the drug being requested is indicated and approved for the condition. 
• Document all related information regarding the PA approval or non-approval. 
• Conform to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision-making. Partner with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing.
• Analyze, research, and resolve prior authorization processing issues, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from supervisor or clinical pharmacists; and referring unique or high dollar requests to supervisor according to guidelines. 
• Coordinate within client system outbound communication to members, physicians, and pharmacies as required to obtain missing information and manage pending requests.
• Document prior authorization-related information and status.
• Make outbound calls to obtain information and answer questions about prior authorization status.
• Protect and maintain confidentiality and privacy of all prior authorization and member information, including following strict protocols for date stamping and storage/security of prior authorization forms and related information.
• Identify and recommend operational improvements.
• Participate in and support all applicable Quality Management initiatives
• Maintain a flexible schedule to meet client needs, as needed 
• Adhere to all policies and procedures
• Take feedback and responsibility for performance
• Adapt to the differences of clients
• Support all Compliance Program activities
• Complete other duties and responsibilities as directed

Requirements

Skills and Experience

• Ability to work in a fast-paced and high-functioning environment and meet deadlines while managing multiple high priorities.
• Moderate-to-high level of medication and disease state knowledge within the scope of pharmacy practice 
• Personal computer literacy and high competency in using Microsoft Word, Excel, Adobe, etc. 
• Strong organizational skills with attention to detail
• Strong oral and written communication skills
• Excellent critical thinking capabilities with a strong attention to detail
• Exceptional customer service skills
• Minimum one-year prior authorization experience preferred
• Health plan or Pharmacy Benefit Manager experience preferred

Education

• High school diploma or equivalent
• Active Certified Pharmacy Technician (State or National License)