Pharmacy Prior Authorization Senior Representative – CarepathRX – Remote

Cigna Healthcare•Georgia Work at Home, IN

3d•Remote

About The Position

The Pharmacy Prior Authorization Senior Representative obtains initial and renewal prior authorizations for Specialty Pharmacy and/or Specialty Infusion services. The role collaborates with clinicians to identify supporting medical documentation in accordance with formulary guidelines and manages quality review of requested prior authorizations. The representative communicates with insurance companies through portals, phone, and fax; confirms plan eligibility; processes test claims; calculates required units and quantity versus day supply; and keeps patients, prescribers, and internal teams informed about insurance denials and appeals. The role also supports timely task completion, customer service, confidentiality, productivity, quality, and effective communication. For employees working from home occasionally or permanently, the internet connection must be through a cable broadband or fiber optic provider with speeds of at least 10 Mbps download and 5 Mbps upload.

Requirements

High school diploma or GED required.
At least 2 years of prior authorization, insurance verification, or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required.
Knowledge of medical terminology required.
Knowledge of payer websites, eligibility, and coordination of benefits required.
Knowledge of plan formularies and authorization requirements required.
Knowledge of pharmacy versus medical payers and authorization required.
Proficient computer skills and Microsoft Office products required.
Good verbal and written communication skills.
Good organizational skills, attention to detail, and ability to multitask.
Computer literacy, including ability to use standard software applications such as Windows and Microsoft Office Suite (Outlook, Word, and Excel).
Ability to maintain confidentiality of patient information.
Ability to provide customer service to internal and external customers.

Nice To Haves

Team-player qualities.
High priority on client satisfaction and customer needs.

Responsibilities

Obtains initial and renewal authorizations for Specialty Pharmacy and/or Specialty Infusion services from insurance companies via portal, phone, or fax.
Ensures initial and renewal authorizations are followed up on in a timely manner.
Interfaces with other departments and identifies medical documentation supporting prior authorization requests.
Notifies the patient, prescriber, and internal teams of the insurance denial and appeals process.
Confirms plan eligibility and processes test claims.
Calculates required units and quantity versus day supply.
Prioritizes and completes assigned tasks on schedule.
Responds to chat and email update requests in a timely manner.
Uses appropriate communication channels to relay problems, concerns, questions, and ideas.
Works effectively while maintaining expected productivity.
Meets quality standards and demonstrates reliability and follow-through on assigned tasks.
Communicates effectively and expresses ideas clearly.
Performs in accordance with system-wide competencies and behaviors.
Performs other duties as assigned.