Pharmacy Prior Authorization Agent-Specialty

American Addiction Centers•Argyle, TX

1d•Remote

About The Position

This role is responsible for completing insurance verification and eligibility checks, collecting and documenting initial pre-certification/authorization information, and initiating the process for obtaining required referrals/authorizations. The agent will work assigned Epic work queues, follow departmental workflows, and communicate issues and improvement opportunities to management. They will maintain positive public relations with patients, families, and staff, and collaborate effectively for information flow. The role requires maintaining knowledge of Medicare, Medicaid, and third-party payer requirements, insurance plans, and accepted insurance plans. The agent will update patients, physician offices, and other parties on prior authorization outcomes via multiple communication methods. They will act as a liaison to initiate and resolve appeals, identify and assist patients with financial assistance programs, and communicate coverage denials and potential patient financial responsibility. The agent will coordinate with patients, clinical teams, and assistance programs for reimbursement or alternative options and manage incoming and outgoing calls.

Requirements

High School Graduate
Typically requires 1 year of experience in health care, insurance industry, pharmacy, or medical background
Demonstrate ability to identify and understand issues and problems.
Examines data and draws logical conclusions based on information available
Ability to problem solve in a high profile and high stress area
Mathematical aptitude, effective communication, and critical thinking skills
Ability to prioritize and organize workload
Excellent Verbal and written communication skills
Demonstrated technical proficiency including experience with insurance authorization/eligibility tools, EPIC, Microsoft Office, Internet browser and telephony systems

Nice To Haves

Knowledge of medical terminology

Responsibilities

Complete insurance verification and eligibility checks.
Collect and accurately document initial pre-certification/authorization information if available.
Initiate the process of obtaining a required referral/authorization if not obtained.
Work assigned Epic work queue, following the department’s workflow process on appropriately transferring, deferring, or removing orders from the work queue.
Proactively communicate issues involving customer service and process improvement opportunities to management.
Maintain excellent public relations with patients, patients’ families and clinical staff as well as demonstrates a willingness and ability to work collaboratively with others for concise and timely flow of information.
Maintain knowledge of and reference materials for Medicare, Medicaid and third-party payer requirements guidelines and policies, insurance plans requiring pre-authorization/referral and a list of current accepted insurance plans.
Update the patient, physician's office, and any necessary parties, through multiple methods as appropriate (including telephone, in-basket messaging, and electronic medical record), regarding responses and outcomes of the prior authorizations.
Act as a liaison between physician's office, patient, and pharmacy benefit manager to initiate and resolve appeals, as needed.
May identify and assist patients with access to internal and external financial assistance programs.
May communicate to the patient and/or physician's office when authorization is not obtained, or services are not covered, and explains the potential financial responsibility.
Coordinate with patient, clinical team, and assistance programs to secure reimbursement or alternative covered options.
Manage incoming and outgoing calls, which may include other Advocate team members, departments, patients, insurance plans and/or copay foundation/assistance programs.

Benefits

Comprehensive suite of Total Rewards
Benefits and well-being programs
Competitive compensation
Generous retirement offerings
Programs that invest in your career development
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program