Pharmacy Authorization Representative II - BioPlus Specialty Pharmacy

Elevance Health•Lake Mary, FL

8d•Hybrid

About The Position

BioPlus Specialty Pharmacy is seeking a Pharmacy Prior Authorization Specialist responsible for the administration of prior authorizations requests for patients whose health plan requires drug prior authorizations for different therapy types. This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. BioPlus Specialty Pharmacy is a proud member of the Elevance Health family of companies. BioPlus offers consumers and providers an unparalleled level of service that’s easy and focused on whole health. Through distinct clinical expertise, digital capabilities, and broad access to specialty medications across a wide range of conditions, they deliver an elevated experience, affordability, and personalized support throughout the consumer’s treatment journey.

Requirements

Requires a HS diploma or GED
A minimum of 2 years of experience processing pharmacy prior authorizations
A minimum of 1 year of experience applying knowledge of Medicare, Medicaid and Managed Care reimbursement guidelines
Any combination of education and experience which would provide an equivalent background.

Nice To Haves

Specialty pharmacy experience highly preferred.
Medical terminology training is preferred.
Prior Authorization experience is highly desired.
Use critical thinking to interpret oncology regimens and supporting clinical documentation, anticipates payer criteria (e.g., step therapy, site-of-care, NCCN-guided rationale), and determine the best authorization strategy and next step is desired.

Responsibilities

Reviews accuracy and completeness of prior authorization information requested and ensures supporting documents are present and meet company set standards.
Assists with the completion of medical necessity documentation to expedite approvals and ensures that appropriate follow up is performed.
Collaborates with other departments to assist in obtaining prior authorizations/appeals.
Documents insurance company interactions and all prior authorization information in the system.
Reviews insurance denials and submits appeals as permitted by payor.
Contacts physician offices as needed to obtain demographic information or medical data.