Pharmacy Authorization Representative II - BioPlus Specialty Pharmacy

Elevance Health•St. Louis, MO

6d•Hybrid

About The Position

The Pharmacy Prior Authorization Specialist at BioPlus Specialty Pharmacy administers prior authorization requests for patients whose health plans require drug prior authorizations for different therapy types. The role requires associates to work in an office 1–2 days per week, with virtual work for the remainder; alternate locations may be considered for candidates within commuting distance of an office. Candidates outside a reasonable commuting distance will not be considered unless an accommodation is granted as required by law. BioPlus Specialty Pharmacy is part of Elevance Health and provides specialty medication access and personalized support to consumers and providers. The position is a non-management, non-exempt role in the Care Support job family, working the first shift.

Requirements

High school diploma or GED, and at least 2 years of experience processing pharmacy prior authorizations, plus at least 1 year of experience applying knowledge of Medicare, Medicaid, and Managed Care reimbursement guidelines; or an equivalent combination of education and experience.
Ability to review prior authorization information and supporting documentation, assist with medical necessity documentation, and document insurance interactions.

Nice To Haves

Specialty pharmacy experience.
Medical terminology training.
Prior authorization experience.
Critical thinking to interpret oncology regimens and supporting clinical documentation, anticipate payer criteria such as step therapy, site of care, and NCCN-guided rationale, and determine an authorization strategy and next step.

Responsibilities

Review prior authorization requests for accuracy and completeness and confirm supporting documents meet company standards.
Assist with medical necessity documentation to expedite approvals and ensure appropriate follow-up.
Collaborate with other departments to obtain prior authorizations and appeals.
Document insurance company interactions and prior authorization information in the system.
Review insurance denials and submit appeals as permitted by the payer.
Contact physician offices as needed to obtain demographic information or medical data.