Specialist I, Prior Authorization
About The Position
The Specialist I, Prior Authorization (PAS) reviews, processes, and troubleshoots incoming prior authorization requests for various medications. The role processes requests accurately in accordance with regulatory and client-specific guidelines, works with team members to meet departmental performance metrics and maintain compliance, and collaborates with clinical staff to ensure requests are processed accurately and promptly. Requests are received by phone, fax, and web submission. The position follows a Monday–Friday, 8:00 a.m.–5:00 p.m. schedule. Remote work is unavailable to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.
Requirements
- High school degree or equivalent.
- Previous customer service experience.
- Ability to consistently interact cooperatively and respectfully with other employees.
- Ability to maintain scheduled hours and demonstrate flexibility to aid in hour coverage.
Nice To Haves
- Post-high-school education, such as L.P.N., Certified Pharmacy Technician, Medical Terminology, or Medical Transcriptionist.
- Previous data entry experience.
- Experience in health insurance, pharmacy insurance, or a managed care organization.
- Prior authorization processing experience.
- Experience in a PBM or managed care call center.
- Experience in a mail or retail pharmacy setting.
- Experience with Medicare and/or Medicaid regulatory guidance.
Responsibilities
- Research and analyze electronic and manual claims, applying troubleshooting skills to resolve issues as permitted by the individual benefit.
- Communicate prior authorization criteria to providers.
- Help providers submit prior authorization requests, provide formulary product information, and communicate request status as a provider help desk specialist.
- Develop and maintain knowledge of Medicare D, Medicaid, and/or Exchange programs.
- Participate in ad hoc or regularly scheduled Prior Authorization projects or projects for other Navitus departments.
- Protect personal health information and comply with HIPAA regulations and confidentiality requirements.
- Use downtime for personal and professional development, including eLearning classes, participation in the Navitus CPhT program, and reviewing available prior authorization processing resources.
- Maintain scheduled hours and demonstrate flexibility to support hour coverage.
- Perform other duties as assigned.
- Participate in, adhere to, and support compliance program objectives.
- Interact cooperatively and respectfully with other employees.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
