Authorization Management Specialist

Amber Specialty Pharmacy•Omaha, NE

About The Position

The Authorization Management Specialist prepares appeal summaries and prior authorizations, corresponds with prescribers’ offices, and documents information in the electronic medical record. The role gathers and evaluates relevant patient history and information, prepares responses, and completes appeals and prior authorizations accurately and promptly. The specialist works with providers, health plans, pharmacy benefit managers (PBMs), patients, and other specialty pharmacies to support authorization decisions and patient access to coverage.

Requirements

Working knowledge of the healthcare industry.
HIPAA training and/or ability to work with and protect highly confidential patient and employee information.
Six months or less of similar or related work experience.
High school diploma or equivalent.
Proficiency with Microsoft Excel, Word, and Outlook.
Understanding of insurance verification and online prescription adjudication.
Strong oral, written, and interpersonal communication skills.
Self-initiative and demonstrated ability to meet tight deadlines.
Ability to work with internal management and staff, outside clients, and vendors.
Working knowledge of Medicare, Medicaid, commercial insurance, and renal programs related to pharmacy, billing, grants, copay cards, prior authorizations, and rejections.
Ability to read and understand abstract information from handwritten patient medical records.
Ability to remain stationary for up to 90% of the time and occasionally move around the office to access files and equipment or attend meetings and events.
Ability to operate a computer and office productivity equipment, communicate information clearly, exchange accurate information, and observe details at close range.
Ability to lift and move paper and supplies around the work area.
Pass required pre-employment drug testing and background checks; a health screening may also apply.

Nice To Haves

Nationally Certified Pharmacy Technician credential; certification application within state-specified criteria is required.
Prior patient assistance program (PAP), prior authorization (PA), and copay card experience.
Previous experience troubleshooting rejected pharmacy claims.

Responsibilities

Initiate and complete prior authorizations and appeals for specialty pharmacy.
Work with providers, health plans, PBMs, and other specialty pharmacies to relay information and provide service.
Contact providers, health plans, PBMs, and patients to obtain the status of pending prior authorizations and appeals.
Submit prior authorization and appeal requests electronically, by phone, or by fax on behalf of physicians or providers, as permitted.
Maintain prior authorization and appeal documents, databases, and records accurately and promptly.
Evaluate and process claims rejected for prior authorization according to company policies and procedures.
Advocate for patients by identifying and assessing coverage issues.
Assist licensed professionals in reviewing patient chart notes and payer requirements to determine appropriate courses of action.
Ensure prior authorization requests and provider appeals are timely and appropriate under state, federal, and company guidelines.
Follow company policies, management directives, and the Accreditation Policy and Procedure manual.
Maintain the confidentiality of personal, financial, strategic, and proprietary information.