Pharmacy Prior Authorization Specialist

Overview

Pharmacy Prior Authorization Specialist – Department:
Quality Department.

Reports to:

Director of Pharmacy. FLSA Classification:
Non-Exempt.

About Primary Health Solutions

Our Mission:
We meet people where they are and partner with them on their journey towards wellness.

Our Vision
:
The destination for servant leaders to provide comprehensive and exceptional care.

Our Values
: R – Respect; I – Innovation; S – Stewardship; E – Excellence.

Summary of the role:

The prior authorization specialist coordinates all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical information from the electronic medical record, and timely communication with patients, prescribers, and provider office staff. Knowledge of third-party reimbursement regulations and medical terminology is required; seek assistance from a pharmacist as necessary. Strong communication, interpersonal, and problem-solving skills are essential.

Ability to interact effectively with internal and external customers, pharmacists, office staff, and all members of the organization.

• Complete and submit prior authorizations for patients receiving medications prescribed by Primary Health Solutions providers using Cover My Meds and Next Gen to ensure accurate information is submitted.
• Evaluate insurance coverage and pharmacy benefits to determine the patient’s ability to pay and identify the need for additional coverage options (e.g., copay cards) based on the outcome of prior authorizations.
• Maintain patient-specific paper and/or electronic files documenting all contact, correspondence, verification, and reason for denial for future reference through Next Gen encounters.
• Act as a liaison between clinical and pharmacy teams and facilitate the triaging of patient needs.
• Review prior authorization denials for appeal opportunities; write and complete the appeal process in collaboration with the PH Solutions pharmacy team.
• Assist in the management of specialty medications in collaboration with community partners.
• Drive prescription volume to in-house pharmacies where appropriate for patient benefit.
• Develop process improvements for expanding the prior authorization process and data collection.
• Maintain effective communication and cooperative relationships with other departments, pharmaceutical companies, medical and support staff, patients, and visitors.
• Perform all other duties as assigned.

None

• Customer Service:
  Commitment to increasing customer satisfaction, setting proper expectations, solving problems, and meeting commitments.
• Communication:
  Clear written and verbal communication, active listening, and interpersonal skills.
• Dependability:
  Meets commitments, works independently, accepts accountability, handles change, maintains punctuality.
• Quality:
  Attention to detail, commitment to excellence, continuous improvement, root-cause analysis, addressing quality issues.
• Productivity:
  Manages workload, prioritizes tasks, develops good procedures, manages time effectively.

To perform this job successfully, the individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Certified Pharmacy Technician (CPhT) required. Proficiency in pharmacy practice.
• Prior Authorization and/or Specialty Pharmacy experience preferred.
• Minimum of 3 years’ experience working as a Pharmacy Technician required.
• Operate standard office equipment.
• Maintains the security and confidentiality of data and information as appropriate to policy, laws, and regulations.
• Handles telephone inquiries and email referrals.
• General knowledge of medical and pharmacy insurance plans, reimbursement and government regulations.
• Developed knowledge of Microsoft Word and Excel.
• Self-motivation and organizational skills.
• Developed knowledge of medications and medical terminology.

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.…