• Initiates and completes prior authorizations and appeals for specialty pharmacy

• Work directly with providers, health plans, PBMs, and other specialty pharmacies to relay vital information and provide a high level of service

• Communicates with providers, health plans, PBMs, and patients to obtain the status of pending prior authorizations and appeals

• Submits prior authorization and/or appeal requests via electronic, phone, or fax on behalf of physicians/providers as allowed

• Assures that all prior authorization and appeal documents, databases, and records are maintained accurately and timely

• Evaluate and process claims rejected for prior authorization following company policies and procedures

• Advocates on the patient's behalf to identify and assess coverage issues

• Assists licensed professionals in reviewing patient chart notes and payer requirements to determine why cases are an appropriate course of action

• Assures timeliness and appropriateness of all PA requests and provider appeals according to state, federal, and company guidelines

• Adheres to all company policies as indicated in the handbook and directives issued by management. Has reviewed Accreditation Policy and Procedure manual

Professional Competencies:

• Proficient with MS Excel, Word, and Outlook

• Understanding of insurance verification and online prescription adjudication

• Strong oral, written, and interpersonal skills

• Self-initiative

• Demonstrated ability to meet tight deadlines

• Ability to work with all levels of internal management and staff, as well as outside clients and vendors

• Working knowledge of Medicare, Medicaid, Commercial Insurance, and renal programs related to pharmacy, billing, grants, co-pay cards, prior authorizations, and rejections

• Prior PAP, PA, and co-pay card experience preferred

• Previous experience troubleshooting rejected pharmacy claims preferred

• Proficiently read and understand abstract information from handwritten patient medical records

Required Qualifications:

• Working knowledge of the healthcare industry

• HIPPA trained and/or the ability to work with and protect highly confidential patient and employee information

• Six months or less of similar or related work experience

Educational Requirements

High school diploma or equivalent

Licensure and Certification Requirement:

• Nationally Certified Pharmacy Technicians preferred

• Application for certification within state-specified criteria

Physical Requirements:

• Must be able to remain in a stationary position up to 90% of the time

• The person in this position must occasionally move inside the office to access file cabinets, machinery, etc., and traverse conferences, meetings, and remote events

• Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer

• The ability to communicate information and ideas so others will understand. Must be able to exchange accurate information in these situations

• The ability to observe details at close range (within a few feet of the observer)

Working Conditions:

Normal office environment.

Equipment Used to Perform the Job:

Computers, keyboards, mouse, monitors, fax, and/or headsets for phone work. Software specific to the position, including but not limited to Microsoft Outlook and Skype. Must lift and traverse the area to move paper and supplies to use the equipment.

Contacts: