Prior Authorization Specialist

Methodist Le Bonheur Healthcare•Memphis, TN

About The Position

The Prior Authorization Specialist is responsible for precertifying eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity. The role ensures that medical documentation is complete and meets insurer guidelines for medical necessity, reimbursement, and payment for services. The specialist reviews provider-submitted clinical information, verifies physician orders, determines CPT, HCPCS, and ICD-10 codes for prior authorization, and makes timely medical necessity determinations using appropriate criteria and standards. The position also coordinates patient assistance and grants for outpatient pharmacy patients in designated areas. It serves as a primary contact for physicians and physician offices to collect clinical documentation, explain precertification protocols, and maintain provider relationships. The specialist communicates requirements to Patient Access, Case Management, and other teams; researches denials and problematic accounts; and identifies trends, root causes, and potential process improvements. The role models behavior consistent with MLH’s mission, vision, and values and has no lead or supervisory responsibilities.

Requirements

High school diploma or equivalent.
Three to five years of experience in pharmacy, including clinical, hospital, outpatient, or specialty pharmacy.
Tennessee Pharmacy Technician license from the Tennessee Board of Pharmacy.
Certified Pharmacy Technician credential from the Pharmacy Technician Certification Board.
Basic understanding of prescription processing flow.
Expertise using EMRs to document clinical criteria required for third-party approval.
Knowledge of medical terminology, drug nomenclature, symbols, and abbreviations associated with pharmacy practice.
Strong attention to detail and critical-thinking skills.
Ability to communicate effectively with patients, associates, and other health professionals.
Ability to diagnose situations and recommend ways to resolve problems.
Experience with a computerized healthcare information system.
Familiarity with fundamental Microsoft Word software.
Excellent verbal and written communication skills.

Nice To Haves

Certified Pharmacy Technician-ExCPT credential from the National Healthcareer Association.
Mississippi Pharmacy Technician license from the Mississippi Board of Pharmacy.

Responsibilities

Precertify eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity.
Ensure medical documentation meets insurer guidelines for medical necessity and payment or reimbursement.
Review clinical information submitted by medical providers to evaluate the necessity, appropriateness, and efficiency of prescription medication use.
Assist with patient assistance and grant coordination for outpatient pharmacy patients from designated areas.
Analyze provider-submitted information and make timely medical necessity review determinations using appropriate criteria and standards.
Verify physician orders and determine CPT, HCPCS, and ICD-10 codes for prior authorization.
Contact insurance companies and third-party administrators to gather information and organize workflow for requested procedures.
Collect, read, and interpret medical documentation to determine whether appropriate clinical information has been provided for insurance reimbursement and proper charge capture.
Serve as the primary contact for physicians and physician offices to collect clinical documentation consistent with insurer reimbursement guidelines.
Maintain rapport with providers and educate them on precertification protocols.
Communicate contract guidelines and precertification requirements to Patient Access, Case Management, and other relevant teams.
Research denials and problematic accounts, identify trends and root causes, and recommend resolutions for future processes.
Model behavior consistent with MLH’s mission, vision, and values.