Senior Prior Authorization Specialist

CareMed Specialty Pharmacy•Woodridge, IL

7d•Hybrid

About The Position

CareMed Specialty Pharmacy is seeking a Senior Pharmacy Prior Authorization Specialist to join our dedicated team in Louisville, KY. This is a full-time position ideal for candidates local to the area. Remote work possible after initial on-site training. This role involves working closely with the Prior Authorization Manager and supervisor to ensure completion of challenging cases and escalations in their designated vertical. The specialist will initiate prior authorizations, complete prior authorization forms via webtools such as CoverMyMeds or insurance specific forms including clinical information from clinical notes provided by prescribers, adjudicate test or live claims to review rejections, and follow up on PA requests with insurance companies, while taking prescriber preferences into account. Senior Prior Authorization Specialists may also assist with training employees, and other duties as assigned.

Requirements

High School Diploma or GED.
Previous Experience in Experience in Pharmacy and Prior Authorizations
2+ years pharmacy or prior authorization experience
Registration with Board of Pharmacy (as required by state law)
Prior authorization process, CoverMyMeds experience, knowledge/understanding of pharmacy insurance claims, Medicare, Medicaid, and commercial insurance, pharmacy test claim and NCPDP claim rejection resolution, coordination of benefits, NDC medication billing, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills.

Nice To Haves

Associates or Bachelor’s Degree
Certified Pharmacy Technician (PTCB), Advanced Certified Pharmacy Technician
3+ years of experience in pharmacy or prior authorizations
Specialty pharmacy experience

Responsibilities

Works and resolve difficult or escalated cases to assist in processing prescription orders
Participates in the orientation and training of prior authorization specialists within workflow vertical.
Escalates workflow/process improvement ideas to leadership
Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests
Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding benefit information.
Runs test claims or live claims to check for payable claims or for valid insurance rejections on medications that require prior authorizations and initiate Prior Authorization requests, using appropriate insurance forms, portals or CoverMyMeds.
Reviews accuracy and completeness of information and ensure supporting clinical documentation is included if required.
Contacts insurance companies and providers to follow up on prior authorization requests, including determining if any additional information is needed, or whether the claim is in review, approved, or denied.
Document all prior authorization information in patient profile.
Facilitates process for requesting and follow up of prior authorizations with prescribers through preferred contact methods noted in prescriber/patient profiles.
Provides guidance to providers and patients in connection with documentation required for payer coverage, support with appeals for denied claims, and follow up with payer to determine outcome.
Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws.
Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.
Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.