Prior Authorization Coordinator I

MedImpact•Tempe, AZ

4d•Onsite

About The Position

The Prior Authorization Coordinator I works on the Prior Authorization Operations team, processing prior authorization requests according to accuracy, timeliness, productivity, and client performance standards. The role uses business applications and drug references to review requests, enter prior authorization data, identify missing information, and make administrative processing determinations under clinical protocols and client guidelines. The coordinator works with internal and external customers to obtain and provide information and deliver quality service, under general supervision that varies according to demonstrated skills and performance. The position is part of a three-level career path with progression opportunities. It requires a GED or high school diploma and at least one year of experience, or an equivalent combination of education and experience. The employee must successfully complete a national certification exam or obtain state licensure, and maintain a current, unrestricted Pharmacy Technician License and/or CPhT certification. This is a full-time, non-exempt position. Typical hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.; overtime and the ability to work nights, weekends, or holidays may be required to meet business needs. The role is on-site at the San Diego headquarters or another company location, with remote work possible with management approval based on business requirements. No travel is required, though attendance at local conferences or meetings may be required.

Requirements

GED or high school diploma and at least one year of experience, or an equivalent combination of education and experience.
Intermediate knowledge of Microsoft Office, including Word, Excel, and Outlook, and aptitude for learning new programs.
Experience with Windows-based database programs.
Must successfully complete one of the national certification exams or obtain state licensure in any U.S. state.
Must maintain a current Pharmacy Technician License and/or CPhT certification without restriction.
Ability to interpret written, oral, diagrammatic, or schedule-form instructions; define problems, collect data, establish facts, and draw valid conclusions.
Ability to perform basic arithmetic and calculate rates, ratios, percentages, and proportions, and interpret bar graphs.
Ability to present information effectively in one-on-one and small-group situations, read and comprehend simple instructions and correspondence, and write simple correspondence.
Ability to work overtime and nights, weekends, or holidays as required.
Ability to meet the physical demands of the role, including regularly sitting, talking or hearing, standing, walking, handling objects, and reaching, and occasionally lifting or moving up to 10 pounds.

Responsibilities

Process, prioritize, enter, and finalize prior authorization requests within client turnaround times and performance guarantees, following applicable guidelines.
Check formulary alternatives and tried-and-failed medications, use drug references, and verify whether requested drugs are indicated and approved for the condition.
Document prior authorization information, status, and approval or non-approval decisions.
Respond to requests from physicians or pharmacies by faxing prior authorization status.
Follow defined roles and boundaries between administrative prior authorization processing and clinical decision-making, partnering with assigned clinical pharmacists as needed.
Meet prior authorization processing productivity and accuracy standards.
Analyze, research, and resolve processing issues appropriate to experience and career path level; make written or telephone inquiries, consult subject matter experts or supervisors, and refer unique or high-dollar requests according to guidelines.
Coordinate notifications to members, physicians, and pharmacies to obtain missing information, manage pended requests, and communicate determinations.
Make outbound calls to obtain information and answer questions about prior authorization status.
Collaborate with MCO and self-insured client teams to understand client processing requirements and expectations.
As appropriate to experience and career path level, partner with client teams on special processing projects and provide accurate, timely information for client claim inquiries.
Collaborate with Contact Center Services to resolve prior authorization inquiries.
Handle provider, pharmacy, and member calls to complete prior authorization and peer-to-peer requests according to client-specific requirements.
Protect the confidentiality and privacy of prior authorization and member information, including following protocols for date stamping and securing forms and related information.