Review completed prior authorization requests and recommendations
Verify member’s ID and date of birth
Check for previous prior authorization decisions
Evaluate whether request meets criteria for approval
Job description
Summary:
Work Mode: 100% Remote - in the U.S.
SHIFT: Mon - Fri 9am – 6pm EST, No OT required
Duration: 3 months (Possible extension)
Responsibilities:
Pharmacy Appeals Department – Dept 247
Review completed prior authorization requests received from the provider and/or review the pharmacy technician’s recommended denial, suggested formulary alternatives, comments, and attachments for appropriateness.
Verify member’s ID number and date of birth.
Verify member’s eligibility in the appropriate health plan eligibility system.
Record carrier and group number if applicable.
Check for previous prior authorization decisions.
Verify coverage in member’s prescription benefit when necessary.
Verify coverage in member’s health plan benefit when necessary.
Evaluate prescription claim history.
Review chart notes and/or lab values.
Identify provider specialty when appropriate.
Apply Medical Policy Criteria to prior authorization requests.
Evaluate whether request meets criteria for approval.
Review the request using professional clinical judgment on a case-by-case basis.
Research and contribute drug references and clinical information to facilitate prior authorization review.
Communicate with physicians regarding prior authorization for non-formulary drugs, plan benefits, exclusions, quantity limits, age restrictions, and formulary alternatives.
Retrieve and collect data through available reporting resources.
Compile data for reporting purposes, including drug utilization of non-formulary drugs and audit pharmacy claims greater than $200.00.
Requirements:
Education/Certification: Required: Pharm D.
Licensure: Required: Any US state
Must have at least one year of professional RPh experience.
Preferred Skills:
Some experience working in managed care, understanding of Medicare/Medicaid law.
