Hospital Pharmacy Authorization Specialist

Methodist Le Bonheur Healthcare•Indianapolis, IN

25d

About The Position

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One! We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South. The Hospital Prior Authorization Specialist is responsible for coordinating and securing prior authorizations for inpatient and outpatient hospital services in accordance with payer requirements and regulatory standards. This position ensures that all necessary approvals are obtained to support timely patient care, optimize reimbursement, and reduce the risk of claim denials. The Specialist collaborates closely with clinical staff, and insurance providers to maintain compliance, accuracy, and operational efficiency. Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence. A Brief Overview Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Requirements

High School Diploma or Equivalent
3-5 years Pharmacy (clinical, hospital, outpatient, or specialty)
See Additional Job Description.
Basic understanding of prescription processing flow.
Expertise in utiliizing EMRs to document clinical critieria required for third party approval.
Knowledgeable of medical terminology, drug nomenclature, symbols and abbreviations associated with pharmacy practice.
Strong attention to detail and critical thinking skills.
Ability to speak and communicate effectively with patients, associates, and other health professionals.
Ability to diagnose a situation and make recommendations on how to resolve problems.
Experience with a computerized healthcare information system required.
Familiarity with fundamental Microsoft Word software.
Excellent verbal and written communication skills.

Responsibilities

Responsible for precertification of eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity.
Ensures medical documentation is sufficient to meet insurer guidelines for medical necessity documentation and procedure payment.
Reviews clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of prescription medications.
Assists with patient assistance and grant coordination for Patients for outpatient pharmacies from designated areas.
Proactively analyzes information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines.
Verifies physician orders are accurate.
Determines CPT, HCPCS and ICD-10 codes for proper Prior Authorization.
Contacts insurance companies and third party administrators to gather information and organize work-flow based on the requested procedure.
Collects, reads and interprets medical documentation to determine if the appropriate clinical information has been provided for insurance reimbursement and proper charge capture.
Serves as primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines.
Establishes and maintains rapport with providers as well as ongoing education of providers concerning protocols for pre-certification.
Communicates information and acts as a resource to Patient Access, Case Management, and others in regard to contract guidelines and pre-certification requirements.
Performs research regarding denials or problematic accounts as necessary.
Works to identify trends and root cause of issues and recommend resolutions for future processes.