Pharmacy Prior Authorization Agent

Advocate Health and Hospitals Corporation•Elm Grove, WI

10d•Remote

About The Position

This is a full-time, remote position within the Enterprise Pharmacy - Patient Assistance department. The Pharmacy Prior Authorization Agent is responsible for completing insurance verification and eligibility checks, initiating the process of obtaining required referrals/authorizations, and managing assigned work queues. The role involves proactive communication with management regarding customer service and process improvement, maintaining positive public relations, and staying knowledgeable about payer requirements. The agent will update patients, physician's offices, and other relevant parties on prior authorization outcomes, act as a liaison to resolve appeals, and may assist patients with financial assistance programs. The position also involves communicating coverage limitations and potential financial responsibilities to patients and physicians, coordinating with various parties to secure reimbursement or alternative options, and managing 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
Operates all equipment necessary to perform the job
Must have the ability to lift to 10 lbs. occasionally
Uses a computer continuously throughout the workday
Must be able to sit for extended periods of time

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

Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance
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