Prior Authorization Spec
About The Position
Support BCBSM/BCN providers (pharmacists and physicians) with Commercial pharmacy/medical drug benefits analysis, drug coverage inquiries, and prior authorizations. Answer telephones in an efficient and timely manner to lend appropriate assistance to providers. Triage prior authorization requests under the supervision of a clinical pharmacist. Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy/medical claims. Communicate coverage determination status to physicians and/or members and effectuate such decisions within the authorization tool. Troubleshoot problems, inquiries, and new processing procedures for coverage determinations. Assist with internal control systems and regulations compliance.
Requirements
- High School Graduate or GED equivalent required.
- Two (2) years of experience in retail or hospital pharmacy required.
- Knowledge of prescription drug names, therapeutic classes, and claims processing.
- Expert knowledge of pharmacy claims processing.
- Understanding of formularies and utilization management edits.
- Computer Literate (Microsoft Office Products).
Nice To Haves
- Two (2) years of college preferred.
- Pharmacy Technician Certification (PTCB) preferred.
Responsibilities
- Support BCBSM/BCN providers (pharmacists and physicians) with Commercial pharmacy/medical drug benefits analysis, drug coverage inquiries, and prior authorizations.
- Answer telephones in an efficient and timely manner to lend appropriate assistance to providers.
- Triage prior authorization requests under the supervision of a clinical pharmacist.
- Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy/medical claims.
- Communicate coverage determination status to physicians and/or members and effectuate such decisions within the authorization tool.
- Troubleshoot problems, inquiries, and new processing procedures for coverage determinations.
- Assist with internal control systems and regulations compliance.
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What This Job Offers
Career Level
Mid Level
Education Level
High school or GED
