Pharmacy Prior Authorization Specialist - BioPlus Specialty Pharmacy

Elevance Health • Lake Mary, FL

6d • Hybrid

About The Position

BioPlus Specialty Pharmacy, a proud member of the Elevance Health family of companies, is seeking a Pharmacy Prior Authorization Specialist. This role is responsible for the administration of prior authorization requests for patients whose health plan requires drug prior authorizations for different therapy types. The specialist will ensure accuracy and completeness of prior authorization information, assist with medical necessity documentation, collaborate with other departments, document interactions in the system, review insurance denials and submit appeals, and contact physician offices as needed. This position is part of a hybrid workforce strategy, requiring associates to be in-office 1-2 days per week.

Requirements

• Requires a HS diploma or GED
• Minimum of 2 years of experience processing pharmacy prior authorizations
• 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.

Benefits

• merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs
• medical
• dental
• vision
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED