Prior Authorization Specialist

SUMMARY:

Support providers (pharmacists and physicians) with Medicare Part D drug coverage inquiries, Grievances, and prior authorizations.

RESPONSIBILITIES/TASKS:

Answer telephones in an efficient and timely manner to lend appropriate assistance to providers.
Process prior authorization requests under the supervision of a Clinical Pharmacist.
Apply pharmacy prior authorization criteria used in the adjudication of pharmacy PA requests.
Analyzing written, faxed, and verbal inquiries which leads to entry of pharmacy authorizations into the system.
Communicate coverage determination status to physicians and/or members and effectuate such decisions within the authorization tool.
Troubleshoot problems, inquiries, and new processing procedures for coverage determinations.
Perform other related duties as assigned.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION OR EQUIVALENT EXPERIENCE:

High School Graduate of GED equivalent required. Two (2) years of college preferred.

EXPERIENCE:

Two (2) years experience in retail or hospital Pharmacy required.
Pharmacy Technician Certification (PTCB) preferred.
Knowledge of prescription drug names, therapeutic classes and claims processing.
Experience with Medicare Part D prescription benefits may be preferred for some positions

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

Knowledge of pharmacy claims processing.
Understanding of formularies and utilization management edits.
Familiarity with Medicare Guidelines and Timeframes.
Computer Literate (Microsoft Office Products).
Ability to read and comprehend simple instructions, short correspondence, and memos.
Ability to write simple correspondence.
Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
Ability to add,...