Specialty Pharmacy Prior Authorization Specialist

Job description

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One! We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South. Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence. A Brief Overview Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. What you will do Responsible for precertification of eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity. Ensures medical documentation is sufficient to meet insurer guidelines for medical necessity documentation and procedure payment. Reviews clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of prescription medications. Assists with patient assistance and grant coordination for Patients for outpatient pharmacies from designated areas. Proactively analyzes information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines. Verifies physician orders are accurate. Determines CPT, HCPCS and ICD-10 codes for proper Prior Authorization. Contacts insurance companies and third party administrators to gather information and organize work-flow based on the requested procedure. Collects, reads and interprets medical documentation to determine if the appropriate clinical information has been provided for insurance reimbursement and proper charge capture. Serves as primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines. Establishes and maintains rapport with providers as well as ongoing education of providers concerning protocols for pre-certification. Communicates information and acts as a resource to Patient Access, Case Management, and others in regard to contract guidelines and pre-certification requirements. Performs research regarding denials or problematic accounts as necessary. Works to identify trends and root cause of issues and recommend resolutions for future processes. Education/Formal Training Requirements Required - High School Diploma or Equivalent Work Experience Requirements Required - Pharmacy (clinical, hospital, outpatient, or specialty) 3-5 years Licenses and Certifications Requirements Required - Pharmacy Technician - Tennessee - Tennessee Board of Pharmacy Required - Certified Pharmacy Technician - Pharmacy Technician Certification Board Preferred - Certified Pharmacy Technician- ExCPT - National Healthcareer Association Preferred - Pharmacy Technician - Mississippi - Mississippi Board of Pharmacy Knowledge, Skills and Abilities Basic understanding of prescription processing flow. Expertise in utiliizing EMRs to document clinical critieria required for third party approval. Knowledgeable of medical terminology, drug nomenclature, symbols and abbreviations associated with pharmacy practice. Strong attention to detail and critical thinking skills. Ability to speak and communicate effectively with patients, associates, and other health professionals. Ability to diagnose a situation and make recommendations on how to resolve problems. Experience with a computerized healthcare information system required. Familiarity with fundamental Microsoft Word software. Excellent verbal and written communication skills. Supervision Provided by this Position There are no lead or supervisory responsibilities assigned to this position. Physical Demands The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion. Must have good balance and coordination. The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently. The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading. The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative. Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity. Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community.