Prior Authorization Specialist

TriHealth•Cincinnati, OH

1d•Hybrid

About The Position

The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical information from electronic medical record, and timely communication with patients, prescribers and physician office staff. Candidates should possess knowledge of third-party reimbursement regulations and medical terminology as well as seek out assistance from a pharmacist or physician as necessary. Success in this role will require strong communication, interpersonal, and problem-solving skills. This person should be able to interact and communicate effectively with internal and external customers, physician office staff, and all members of the organization.

Requirements

High School Degree or GED in Pharmacy; Pharmacy Technician or Medical Assistant
2-3 years’ experience Clinical Pharmacy Technician or Medical Assistant

Nice To Haves

Certified Pharmacy Technician or Certified Medical Assistant desired
Prior experience with medication Epic and/or prior authorizations desirable

Responsibilities

Research and investigate Prior Authorization (PA) requirements by insurance company
Obtain Prior Authorization status updates from the insurance company and communicate to patient, pharmacy, or physician’s office as necessary
Submit Prior Authorization application forms and all required supporting documentation to the insurance company
Review medical record to obtain necessary patient demographic and clinical information and seek timely clarification from pharmacist or physician as necessary
Review Prior Authorization denials and communicate reasons for denial to physicians and patients
Serve as a subject matter expert for drug formularies and the prior authorization process in general
Follows up with insurance companies in a timely manner regarding Prior Authorizations
Provides excellent customer service as evidenced by a willingness and ability to assist customers (both internal and external) with their questions/concerns, treating customers in a friendly and helpful manner, and maintaining a positive attitude
Demonstrates the ability to prioritize daily tasks and has a working knowledge of department’s day-to-day operations and initiatives.
Is an active participant in meetings, work groups, and committees.
Participates in departmental and organizational feedback opportunities.
Assists in the training of new employees.
Meets or exceeds department's internal quality performance metrics.
Participates in quality improvement activities and projects to monitor the effectiveness of department's services.
Meets or exceeds department’s customer satisfaction targets and goals.
Assumes responsibility for achieving department satisfaction goals and demonstrates a commitment to service excellence for internal and external customers.
Proactively communicates with patients and physician office staff.
Serves as a subject matter expert for the prior authorization process.
Meets or exceeds department’s goals for formulary adherence measures, and other cost control initiatives identified as a priority for the department.
Works collaboratively with pharmacists, prescribers, physician office staff and all members of the health care team to coordinate all aspects of the prior authorization process and documents activities appropriately in the electronic medical record.