Specialist III, Prior Authorization

Navitus Health Solutions, LLC•,

3d•$20 - $23•Remote

About The Position

Navitus Health Solutions is seeking a Specialist III, Prior Authorization to join their team. This role functions as a subject matter expert (SME), the first point of escalation for all issues, and the lead contact between Prior Authorization Specialists III (PASIIIs), the Prior Authorization team, and other Navitus departments. The PASIII acts as a liaison and guide/mentor for Prior Authorization Specialists and Leadership, assisting with the resolution of short-term and long-term service issues. The PASIII performs high-level Prior Authorization functions and tasks as needed, while also participating in the daily production workload when required. The Specialist III, Prior Authorization is proficient in reviewing, processing, and troubleshooting incoming Prior Authorization requests in both Prior Authorization systems and provides oversight on all Medicare D requests. Additional responsibilities include participation in new associate training, assisting with the implementation of regulatory changes, quality monitoring, researching privacy incidents, assisting in audits, and assisting with the maintenance of the Prior Authorization Compass site and department policies and procedures. The PASIII collaborates with other Navitus departments, vendors, and clients as necessary to resolve issues affecting Prior Authorization. The PASIII coordinates timely and effective communications to and from the PASIIIs to Leadership and represents the Prior Authorization department in interdepartmental meetings and projects.

Requirements

High school degree or GED required.
1 year of experience in Navitus Prior Authorization and high-level knowledge of Prior Authorization processes required.
Passing audit scores within the past 6 months required.
Previous customer service experience required.
Participate in, adhere to, and support compliance program objectives.
The ability to consistently interact cooperatively and respectfully with other employees.

Nice To Haves

Post-high school education desired such as L.P.N., Certified Pharmacy Technician, Medical Terminology, or Medical Transcriptionist.
Experience in health insurance/pharmacy insurance or managed care organization preferred.
Experience in a PBM or managed care call center desired.
Experience in a mail or retail pharmacy setting desired.
Experience with Medicare and/or Medicaid regulatory guidance desired.

Responsibilities

Abide by all departmental policies and procedures.
Demonstrate appropriate workload management, attitude, and performance.
Act as a model for Prior Authorization staff.
Function as subject matter expert (SME) by actively managing and resolving issues timely.
Provide education, direction, and guidance to staff on managing inquiries.
Coach staff through resolution and/or further escalating issues to Leadership as appropriate.
Identify barriers to productivity and create action plans to improve efficiencies and productivity.
Investigate trends, identify root problems, and work to remove barriers.
Participate in quality initiatives, including performance monitoring and auditing.
Identify process improvements, educational opportunities, and implement change.
Provide department-specific training for associates; Develop/ maintain department-specific training documents and workflows.
Assist with maintenance and integrity of the Prior Authorization written policies to ensure they are accurate, comprehensive, and clear.
Participate in the maintenance of the Prior Authorization Compass sites.
Assist with prior authorization system support to include release testing and training/ support documentation.
Consistently meet/exceed performance standards.
Act as SME and first point of escalation for questions/issues.
Develop and maintain expert knowledge of Medicare D, Medicaid, and/or Exchange programs.
Monitor and manage volume; ensure workload is prioritized appropriately.
Document and communicate processes and changes to those processes.
Assist with preparation/validation of reports.
Maintain a flexible schedule that accommodates needs of Prior Authorization.
Ensure a professional business environment is maintained at all times by Prior Authorization staff.
Represent Prior Authorization in interdepartmental meetings and participate in implementation activities for new initiatives and enhancements.
Other duties as assigned.