Prior Authorization Coordinator I

MedImpact Healthcare Systems, Inc.•San Diego, CA

2d•$18 - $27•Onsite

About The Position

Works as a member of the Prior Authorization Operations team. Processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments. Uses various business applications to perform analysis, obtain information, and enter prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based upon clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.). Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality. Works under general supervision, relying on instructions, work process guidelines, policies & procedures, and company knowledge/experience to perform the functions of the job. Extent of supervision ranges from close, to moderate, to minimal oversight based upon demonstrated skill and performance levels as defined for the position. This position is part of a three level career path with progression opportunities described in the Core Processing Career Path/Succession Planning Guidelines.

Requirements

GED/HS Diploma and 1+ year experience or equivalent combination of education and experience
Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs. Experience with Windows based database programs is also required.
Must successfully complete one of the national certification exams OR obtain state licensure (in any U.S. State). Maintains a current Pharmacy Technician License and/or CPhT certification without restriction.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence.
Composure
Decision Quality
Organizational Agility
Problem Solving
Customer Focus
Drive for Results
Peer Relations
Time Management
Dealing with Ambiguity
Learning on the Fly
Political Savvy

Responsibilities

Process and finalize Prior Authorization (PA) requests within clients’ turnaround time and Performance Guarantees utilizing guidelines. Enter PAs into the system and prioritize requests. Check formulary alternatives, review tried and failed medications. Utilize drug references and verify the drug being requested is indicated and approved for the condition. Document all related information regarding the PA approval or non-approval. Respond to requests by faxing status of the PA to the physician or pharmacy
Conforms to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making. Partners with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing.
Accountable to achieve prior authorization processing productivity and accuracy standards.
Analyzes, researches, and resolves prior authorization processing issues as appropriate for experience and career path level, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from team subject matter experts (SME) or supervisor; and referring unique or high dollar requests to supervisor according to guidelines.
Coordinates notifications to members, physicians, and pharmacies as required to obtain missing information, manage pended requests, and communicate prior authorization determinations. Documents prior authorization related information and status. Makes outbound calls to obtain information and answer questions about prior authorization status.
Collaborates with MCO and Self-Insured client teams to understand PBM clients’ prior authorization processing requirements and expectations. As appropriate for experience and career path level, partners with client teams to complete special prior authorization processing projects and provide accurate, timely, and reliable information to client claim inquiries. (PAC II/II)
Collaborates with Contact Center Services in resolving prior authorization inquiries
Handling Provider, Pharmacy and member calls to complete prior authorization and Peer to Peer requests based on client specific requirements
Protects and maintains confidentiality and privacy of all prior authorization and member information, including following strict protocols for date stamping and storage/security of prior authorization forms and related information.