Medication Prior Authorization Specialist

1.0 FTE / 40 hours per week

The Medication Prior Authorization Specialist is responsible for coordinating the entire Prior Authorization process with third party payers to ensure that patients are able to obtain their medications in a timely manner. Serves as the primary liaison between the ordering provider, third party payer, clinic departments, and the patient.

Essential Duties and Responsibilities:

• Contacts insurance companies and third-party payers to verify patient benefits, coverage, and policy limitations.
• Coordinates and processes medical Prior Authorizations for pharmaceuticals by submitting information needed for coverage.
• Collaborates with clinical departments to collect patient medical information required by the payer to authorize medications.
• Collaborates with Business Office to update patient account information and status.
• Ensure professional communication with patients, clinic personnel, and outside vendors whether over the phone, via email or other written documentation and respond to all inquiries.
• Make outbound phone calls to patients or insurance companies as follow up to unpaid, denied or rejected medication authorizations and document according to current policy.
• Able to triage incoming calls and requests from clinician groups/patient for authorization of services, questions, status updates.
• Ensures timely initiation and follow up of Medication Prior Authorization requests.
• Maintains records and documents patient information in the EMR.
• Ensures HIPAA guidelines and strict patient confidentiality are maintained.
• Maintain a working knowledge of health care plan requirements and health plan networks.
• Verify and document insurance information as defined by current business practices.
• Research denials, rejections and/or excessive reductions.
• Prioritize workload while being flexible to meet the expectations of the daily operations.
• This position description will be reviewed periodically as duties and responsibilities change with business necessity.
• Any and all other duties as assigned.

Knowledge, Skills, and Abilities:

• Working knowledge of Prior Authorization, medical insurance/billing, and ICD 10 coding processes and procedures
• Knowledge of basic medical terminology
• Comply with all applicable laws and regulations, (e.g., HIPAA, Stark, OSHA, employment laws, etc.)
• Demonstrate prompt and reliable attendance
• Work in the clinic as well from home
• Work at an efficient and productive pace, handle interruptions appropriately and meet deadlines
• Work independently with minimal supervision
• Excellent customer service and communication skills required

Physical Requirements:

• Travel independently throughout the facility with frequent bending, lifting, standing, stooping or sitting for long periods of time may be required
• Use visual and auditory acuity frequently.
• Repetitive motion of upper body required for extended use of computer.
• Communicate via spoken, written or electronic word with patients and family, staff, pharmacies, third party payors and other outside agencies on a frequent basis.

Qualifications:

• High school diploma/GED or equivalent
• 3 years of experience in a medical business office setting or clinical assistant role
• EMR experience required