About the Role
Job Description: **Job Title: Prior Authorization Specialist**
**Location: Fully remote**
**Duration: 12 months contract**
Job Description:
- Prior Authorization Specialist takes in-bound calls from providers, pharmacies, members, etc providing professional and courteous phone assistance to all callers through the criteria based prior authorization process.
- Maintains complete, timely and accurate documentation of reviews.
- Transfers all clinical questions, escalations and judgement calls to the pharmacist team.
- The Rep I, Clinical Services will also assist with other duties as needed to include but not limited to: outbound calls, reviewing and processing Prior Auth’s received via fax and ePA, monitoring and responding to inquiries via department mailboxes and other duties as assigned by the leadership team.
- Work closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business and in accordance with Medicare Part D CMS Regulations.
- Must apply information provided through multiple channels to the plan criteria defined through work instruction.
- Research and conduct outreach via phone to requesting providers to obtain additional information to process coverage requests and complete all necessary actions to close cases.
- Responsible for research and correction of any issues found in the overall process.
- Phone assistance is required to initiate and/or resolve coverage requests.
- Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed.
- Must maintain compliance at all times with CMS and department standards.
- Position requires schedule flexibility and additional cross training to learn all lines of business.
- Flexibility for movement to different parts of the business to support volume where needed.
Responsibilities:
- Utilizing multiple software systems to complete Medicare appeals case reviews
- Meeting or exceeding government mandated timelines
- Complying with turnaround time, productivity and quality standards
- Conveying resolution to beneficiary or provider via direct communication and professional correspondence
- Acquiring and maintaining basic knowledge of relevant and changing Med D guidance
- Effectively manage work volume by handling inbound calls/fax/ePA requests utilizing appropriate courteous and professional behavior based upon established standards.
- Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.
- Communication with other internal groups regarding determination status and results (seniors, pharmacists, appeals, etc).
- Identify and elevate clinical inquiries to the pharmacist team as appropriate.
Experience:
- 0-3 years in a customer service or call center environment managing 75 calls/day.
- Six months of PBM/pharmaceutical related work strongly desired
- At least two years of general business experience that includes problem resolution, business writing, quality improvement and customer service
Skills:
- Prior Authorization
- Medicare and Medicaid
- Call handling experience.
Education:
- High School diploma or GED