Prior Authorization Coordinator I

Exemption Status:United States of America (Non-Exempt)
$17.69 - $22.55 - $27.41
“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”
This position is not eligible for Sponsorship.
MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!
Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.
At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!
Job Description
Summary
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 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.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
Process and finalize Prior Authorization (PA) requests within clients’ turnaround time and Performance Guarantees utilizing guidelines. Enter 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
Process and finalize Prior Authorization (PA) requests within clients’ turnaround time and Performance Guarantees utilizing guidelines. Enter 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. (PAC II/II)
Collaborates with Contact Center Services in resolving prior authorization inquiries
Handling Provider, Pharmacy and member calls to complete prior authorization and Peer to Peer requests based on client specific requirements
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.
No supervisory responsibilities
Education and/or Experience
GED/HS Diploma and 1+ year experience or equivalent combination of education and experience
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 any U.S. State). Maintains a current Pharmacy Technician License and/or CPhT certification without restriction.
Other Skills and Abilities
None required
Reasoning Ability
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Mathematical Skills
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Language Skills
Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
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Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence.
Competencies To perform the job successfully, an individual should demonstrate the following competencies:
Composure
Decision Quality
Organizational Agility
Problem Solving
Customer Focus
Drive for Results
Peer Relations
Time Management
Dealing with Ambiguity
Learning on the Fly
Political Savvy
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made