Prior Authorization Guidelines Specialist I

MedImpact Healthcare Systems, Inc.•San Diego, CA

13d•$23 - $38•Onsite

About The Position

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Requirements

CL05 - AA and 2+ years’ 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 an U.S. State or Territory). Maintains a current Pharmacy License and/or CPhT certification without restriction.
Demonstrates ability to appear for work on time, follow directions from a supervisor, interact well with co-workers, understand and follow work rules and procedures, comply with corporate policies, goals and objectives, accept constructive criticism, establish goals and objectives, and exhibit initiative and commitment.
Understanding of managed pharmacy benefit concepts including formularies, prior authorizations, edits, and claim adjudication.
Self-starter with the ability to work independently and as part of a team.
Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form.
Ability to deal with problems involving several concrete variables in standardized situations.
Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.
Ability to deal with problems involving a few concrete variables in standardized situations.
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 read and comprehend simple instructions, short correspondence, and memos.
Ability to write simple correspondence.
Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

Nice To Haves

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Responsibilities

Provide technical and administrative support to the Fee-For-Service (FFS) Medicaid department, primarily by working directly with the client teams, Clinical Program Managers (CPMs), Clinical Specialists, and Clinical PA Guidelines/Drug Information Management staff to create and support the appropriate administration of pharmacy information to include Medication Request Guidelines, Medication Request Forms (MRFs), and electronic rules.
Support PA in researching PA-related tasks, PA Implementation and perform Prior Authorization processing as needed.
Create and maintain PA Guidelines documents (content management, file maintenance and archiving, coding and linking in on-line electronic systems).
Provide technical and administrative support to the Clinical Program Manager, Clinical PA Guidelines, Drug Information and PA&UM staffs with the Medication Request process to include formatting, verifying and testing of client Medication Request Guidelines (custom and standard) and formatting/development of Medication Request Forms (MRFs) and electronic rules.
Communicate with clients to obtain client authorization of final documents and ensure timely distribution of documentation to appropriate departments.
Direct the timely and accurate communication of information to appropriate department staff to include: Medical Exception/Prior Authorization; Medication Request Forms (MRFs); Clinical Document Maintenance, electronic prior authorization and formulary management rules, and associated tools and programs.
Manage review/QA process for medical exception/prior authorization guidelines prior to implementation and distribution to clients or internal users.
Serve as subject matter expert on processes related to the procedures necessary to ensure effective maintenance of MedImpact Prior Authorization program, and as a resource for PA guidelines related questions and/or inquiries from both internal and external customers.