Prior Authorization Coordinator I
The Scoop:
Works as a member of the Prior Authorization Operations team. Processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments. Uses various business applications (MedAccess, FileNet, RightFax, etc.) to perform analysis, obtain information, and enter prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based upon 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. Works under general supervision, relying on instructions, work process guidelines, policies & procedures, and company knowledge/experience to perform the functions of the job. Extent of supervision ranges from close, to moderate, to minimal oversight based upon demonstrated skill and performance levels as defined for the position. This position is part of a three level career path with progression opportunities described in the Core Processing Career Path/Succession Planning Guidelines.
What You Get To Do:
· Process and finalize PA requests within clients’ turnaround time (TAT) and Performance Guarantees (PGs) utilizing guidelines
· Enter prior authorizations (Pas) into the system and prioritize requests
· Check formulary alternatives, 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
· Respond to requests by faxing status of the PA to the physician or pharmacy
· Conforms to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making
· Partners with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing
· Accountable to achieve prior authorization processing productivity and accuracy standards
· Analyzes, researches, and resolves prior authorization processing issues as appropriate for experience and career path level, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from team subject matter experts (SME) or supervisor; and referring unique or high dollar requests to supervisor according to guidelines
· Coordinates notifications to members, physicians, and pharmacies as required to obtain missing information, manage pended requests, and communicate prior authorization determinations
· Documents prior authorization related information and status
· Makes outbound calls to obtain information and answer questions about prior authorization status
· Collaborates with MCO and Self-Insured client teams to understand PBM clients’ prior authorization processing requirements and expectations
· As appropriate for experience and career path level, partners with client teams to complete special prior authorization processing projects and provide accurate, timely, and reliable information to client claim inquiries
· Collaborates with Contact Center Services in resolving prior authorization inquiries and handling incoming calls during periods of high volume
· Protects and maintains 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
Supervisory Responsibilities
This job has no supervisory responsibilities.
Education and/or Experience
For consideration candidates will need:
- Associate's degree (A.A.) or equivalent from two year College or technical school; and one (1) year related experience and/or training; or equivalent combination of education and experience
- 1 years of Healthcare organization, retail or mail order pharmacy, or PBM experience preferred
Computer Skills
Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs. Experience with Windows based database programs is also required.
Certificates, Licenses, Registrations
Must successfully complete one of the national certification exams OR obtain state licensure (in an U.S. State or Territory). Maintains a current Pharmacy Technician License and/or CPhT certification without restriction.
Other Skills and Abilities
Demonstrates ability to appear for work on time, follow directions from a supervisor, interact well with co-workers, understand and follow work rules and procedures, comply with corporate policies, goals and objectives, accept constructive criticism, establish goals and objectives, and exhibit initiative and commitment.
Understanding of managed pharmacy benefit concepts including formularies, prior authorizations, edits, and claim adjudication. Working knowledge of customer service in a retail/outpatient pharmacy environment. Familiarity with pharmacy software data submission requirements. Self-starter with the ability to work independently and as part of a team that includes clinical pharmacists and other PACs. Attention to detail with a high degree of accuracy. Ability to prioritize and multi-task when presented with multiple duties.
Travel
This position does not require travel, however attendance maybe required at various local training sessions and/or meetings.
