Pharmacy Prior Authorization Specialist

Description

Pharmacy Prior Authorization Specialist

Department:
Quality Department

Reports to:

Director of Pharmacy

FLSA Classification:
Non-Exempt

About Primary Health Solutions

Our Mission

We meet people where they are and partner with them on their journey towards wellness.

Our Vision

The destination for servant leaders to provide comprehensive and exceptional care.

Our Values

R – Respect

I – Innovation

S – Stewardship

E – Excellence

Pharmacy Prior Authorization Specialist Summary

The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical information from electronic medical record, and timely communication with patients, prescribers and provider office staff. Candidates should possess knowledge of third-party reimbursement regulations and medical terminology as well as seek out assistance from a pharmacist as necessary. Success in this role will require strong communication, interpersonal, and problem-solving skills.

This person should be able to interact and communicate effectively with internal and external customers, pharmacists, office staff, and all members of the organization.

A Day in the Life

• Complete and submit prior authorizations for patients receiving medications prescribed by a Primary Health Solutions providers using Cover My Meds, and Next Gen to ensure accurate information is being submitted.
• Evaluate insurance coverage and pharmacy benefits to determine patient’s ability to pay for medications and identify the need for additional coverage options such as copay cards based on the outcome of Prior Authorizations.
• Maintain patient specific paper and/or electronic files to document all contact, correspondence, verification, and reason for denial for future reference through Next Gen encounters.
• Act as a liaison between clinical and pharmacy teams and facilitate the triaging of patient needs.
• Review prior authorization denials for appeal opportunities. Write and complete the appeal process in collaboration with the Primary Health Solutions pharmacy team.
• Assist in the management of specialty medications in collaboration with our community partners.
• Drive prescription volume to our in-house pharmacies where appropriate for patient’s benefit.
• Develop process improvements for expanding the prior authorization process and data collection.
• Maintain effective communication and cooperative working relationships with other departments, pharmaceutical companies, members of medical and support staff, patients, and visitors.
• Performs all other duties and tasks as assigned.

Supervisory Responsibilities None

Core Competencies

• Customer Service: Committed to increasing customer satisfaction, set proper customer expectations, assume responsibility for solving customer problems, ensure commitments to customers are met.
• Communication: Understand and communicate effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.
• Dependability: Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.
• Quality: Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.
• Productivity: Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, and handles information flow.

Requirements

Success Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience

• Certified Pharmacy Technician (CPhT) required. Proficiency in pharmacy practice.
• Prior Authorization and/or Specialty Pharmacy experience preferred.
• Minimum of 3 years’…