Pharmacy Prior Authorization Tech

Dupage Medical Group•Downers Grove, IL

35d•$16 - $25

About The Position

The Health Plan Services Pharmacy Prior Authorization Tech supports designated Duly provider sites in obtaining pharmacy prior authorizations for their members in need of medications that are identified by the respective health plan as needing prior authorization and review as well as requests originating from pharmacies. Accountable for processing medication requests with the patient's health plan or pharmacy carrier.

Requirements

Certified Pharmacy Technician (i.e. NHA/ExCPT) required
HS Diploma required
2-3 years of pharmacy technician experience required
Medications, generic substitutions/alternatives, office ordering practices regarding medication lab requirements and refills knowledge required
Epic system preferred or familiar with other EMR/EHR systems required
Understanding of the medical insurance industry and health plans required
Proficient computer navigation skills, with advanced Microsoft Office/Outlook and intra/internet experience required
Medical Terminology Knowledge required
Effective communication skills required

Nice To Haves

Associates Degree strongly preferred
2+ years pharmacy or health insurance office experience strongly preferred
Epic system preferred or familiar with other EMR/EHR systems required

Responsibilities

Data Collection and Documentation
Receives and documents, telephonic, and/or electronic requests for medications that require prior authorizations - source of request is from Primary Care Physicians, Specialists and Ancillary providers
Verifies member eligibility and basic benefit coverage levels including obtaining information on coordination of benefits and third party liability as appropriate
Utilizes computer resources and available resources both internal and external, to determine provider networks
Evaluates each Prior Authorization request to ensure the request including codes, place of service, service type, provider, and all required medical information is available for submission to insurance carrier or approving entity
Investigates and obtains from providers, missing medical information required for Prior Authorization submission
Maintains accurate and appropriate documentation and follows patient privacy in accordance with HIPPA and Duly policies and procedures
Interface with Health Plans and Provider offices
Contacts physician offices, pharmacies, review organizations and insurance companies to obtain prior approval requirements, and submit appropriate forms and clinical documentation
Works with physician offices to provide ongoing education regarding prior authorization process and requirements
Maintains a current working knowledge of all health plan carrier requirements as it relates to requests for prior authorizations and approval path requirements (pre-determinations and peer to peers)
Applies clinical knowledge and application of health plan formularies, ICD-9 and CPT coding, as well as medical terminology for appropriate communication with physicians and providers
Functions as a resource to physician/provider offices regarding prior authorization requirements, networks, and alternate medication availability as recommended by the patients' health plan
Provides source of prior approval request with timely notification of approval or denial decisions through designated communication routes
System enter and other functions
Performs data entry/processing of prior authorization requests through the EPIC system, and edits Prior authorization notes with appropriate information as outlined per department guidelines and procedures
Maintains accurate and detailed prior authorization notes and patient chart documentation entries
Resources Team Lead or Supervisor/Manager for review of complex requests and issues
Provides input to Team Lead and Supervisor/Manager regarding improvements to operating practices
Assists with orientation and training of new staff

Benefits

Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance and medical coverage at 100% (after deductible) when utilizing a Duly provider.
Employer provided life and disability insurance.
$5,250 Tuition Reimbursement per year.
Immediate 401(k) match.
40 hours paid volunteer time off.
A culture committed to community engagement and social impact.
Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

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