RX Prior Authorization Coord

Overview

About Moda. Founded in Oregon in 1955, Moda is a company focused on building a better future for healthcare, offering outstanding coverage to members, compassionate support to the community, and comprehensive benefits to employees. Moda values diversity and inclusion in the workplace and invites applications from candidates who share this commitment. Our diverse experiences and perspectives help us become a stronger organization.

Utilizes the electronic prior authorization (PA) platform to process pharmacy PAs in accordance with clinical criteria and plan benefits while ensuring that the necessary data is inputted into the claims adjudication system for successful claims processing. This is a full-time work-from-home role.

$20.88 - $23.49 hourly (depending on experience). Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K
  - Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

• High School diploma or equivalent required. College degree preferred. Equivalent work experience in health care administration, pharmacy, or other health related fields may substitute for the education requirement.
• Minimum one year working experience in a prior authorization or technician role in a pharmacy or health plan.
• State Pharmacy Technician license required for all external applicants. Internal applicants are required to obtain one within six months of hire date. CPhT is preferred but not required.
• Demonstrated critical decision making, ability to interpret benefit contracts, clinical criteria and Moda Health administrative policies.
• Demonstrated working knowledge of medical and pharmaceutical terminology and computer skills including Microsoft Office products (proficiency with Word and Excel). Must be able and willing to learn a third-party real-time interactive PBM claims adjudication system, where great attention to detail is imperative.
• Ability to gain proficiency in Moda internal systems, electronic PA platform and PBM claims processing systems.
• Typing proficiency of 40 wpm on a computer keyboard.
• Willingness to work hours necessary to successfully accomplish assigned tasks.
• Ability to anticipate needs and multi-task; consistently meet quality and production standards; maintain confidentiality; project a professional business image; be flexible and adapt to change; handle stress and pressure.
• Sound analytical problem solving, decision making, memory retention, and organizational skills.
• Excellent verbal, written, and interpersonal communication skills including active listening, teamwork, working respectfully with co-workers and members.
• Preference for fast-paced, production-oriented environment.
• Must have the ability to resolve pharmacy conflicts in a professional manner.
• Ability to come to work on time and daily.

• Accountable for accurately entering PAs into multiple systems, tracking requests, and meeting timeline requirements for decisions and notifications of decisions to members and providers according to corporate policy and government regulations.
• Responsible for the first pass assessment and evaluation of the PA request prior to higher level review: prepares, assesses, evaluates, and makes initial determination on the PA request with the information received using established criteria.
• Utilizes critical decision-making skills to interpret formulary coverage and reviews PA requests according to coverage criteria and plan benefits. Prepares necessary documentation and triages requests to the clinical team to determine the outcome.
• Interprets contracts (evidence of coverage, handbooks, summary of benefits etc.) and determines actions required.
• Solves pharmacy plan benefit and formulary issues for members of multiple commercial and ACA plans. Must be able to accurately distinguish member benefit plans and determine member eligibility across varying lines of business and according to varying State requirements.
• Screens requests for formulary status (e.g., PA required, non-formulary excluded, quantity limits, etc.).
• Monitors pharmacy turn-around time deadlines and takes action to ensure required timelines are met. Adheres to timelines set forth by the National Committee for Quality Assurance (NCQA).
• Determines whether additional information is needed from the requesting provider’s office and triages the request to the Rx Assistants.
• Communicates PA decisions and ensures appropriate feedback and follow-up for all PA requests via electronic interface, fax, telephone, and/or email to requesting providers, members, pharmacies, and internal departments within the promissory time frames.
• Supports, tracks, maintains and ensures data and documentation for member appeals, grievances and complaints are provided within necessary timelines.
• Interacts with providers and provider offices via…