Primary Duties and Responsibilities:

• Initiates and completes prior authorizations and appeals for specialty pharmacy for all patients of an assigned product program.

• Work directly with providers, health plans, PBMs, and other specialty pharmacies to relay vital information and provide a high level of service.

• Communicates with providers, health plans, PBMs, Pharma partners, and patients to obtain status of pending prior authorizations and appeals.

• Submits prior authorization and/or appeal requests via electronic, phone or fax on behalf of physicians/providers as allowed.

• Assures that all prior authorization and appeal documents, databases, and records are maintained accurately and timely.

• Collaborates with program team members on other aspects of the product program, not limited to intake and patient access functions and patient communications and onboarding.

• Advocates on the patient’s behalf to identify and assess coverage issues.

• Assists licensed professionals in reviewing patient chart notes and payer requirements to determine why cases are an appropriate course of action.

• Assures timeliness and appropriateness of all PA requests and provider appeals according to state, federal, and company guidelines.

• Adheres to all company policies as indicated in the handbook and directives issued by management. Has reviewed Accreditation Policy and Procedure manual.

• This is an office-based position.

Professional Competencies:

• Proficient with MS Excel, Word, and Outlook

• Understanding of insurance verification and online prescription adjudication

• Strong oral, written, and interpersonal skills

• Self-initiative

• Demonstrated ability to meet tight deadlines

• Ability to work with all levels of internal management and staff, as well as outside clients and vendors

• Working knowledge of Medicare, Medicaid, Commercial Insurance and renal programs related to pharmacy, billing, grants, copay cards, prior authorizations, and rejections

• Prior PAP, PA, and copay card experience preferred

• Prior experience troubleshooting rejected pharmacy claims preferred

• Proficiently read and understand abstract information from handwritten patient medical records

Educational and Experience Requirements:

• High school diploma or equivalent

• Working knowledge of the healthcare industry

• HIPPA trained and/or the ability to work with and protect highly confidential patient and employee information

• Six months or less of similar or related work experience

Licensure and Certification Requirement:

Nationally Certified Pharmacy Technicians Preferred

Physical Requirements:

• Must be able to remain in a stationary position –up to 90% of the time

• The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc., and traverse conferences, meetings, and remote events

• Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer

• The ability to communicate information and ideas so others will understand. Must be able to exchange accurate information in these situations

• The ability to observe details at close range (within a few feet of the observer)

Equipment Used to Perform the Job:

Computers, keyboards, mouse, monitors, fax, and/or headsets for phone work. Software specific to the position, including but not limited to Microsoft Outlook and Skype. Must lift and traverse the area to move paper and supplies to use the equipment.

Contacts:

Frequently interact with co-workers, intradepartmental staff of the Company, managers, leaders, vendors, insurance carriers, government entities, such as Medicare/Medicaid, and customers.

Confidentiality:

The position Interactions with medical personnel and patients and access proprietary and medical (HIPAA) information in various interactions and matters.