Prior Authorization Representative

Description:

• Conducts an initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
• Routes cases directly to the pharmacist/medical director for final determination, as directed.
• Issues verbal and written member notification as required.
• Reviews and interprets prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of Prior Authorization review is required, documents any relevant medication history and missing information to assist the pharmacist/nurse/physician in the review process.
• Develops and implements process improvement to increase efficiency in the review process for the clinical staff.
• Works with requesting providers, clinical pharmacists, and other internal staff, as appropriate, in determining whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy and specific coverage criteria.
• Can point out nuances that may not be readily apparent regarding the request.
• Contacts pharmacies and physician offices as necessary to obtain clarification on Prior Authorization requests and drugs being billed through the point-of-sale system and/or medical claim system in order to optimize the member experience.
• Acts as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy and/or medical claims with Prior Authorization information on file or needed for the member.
• Responsible for assuring appropriate authorization entry across all lines of business. Ensure care management system interfaces to claim processing system for claim payment. Manual manipulation of authorization may be required upon case completion.
• Performs system testing as required for upgrades and enhancements to the care management system.
• Acts as a content expert for Prior Authorization intake for our customers, both internal and external

Experience Level:

Expert Level

About Aston Carter:

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At Aston Carter, we’re dedicated to expanding career opportunities for the skilled professionals who power our business. Our success is driven by the talented, motivated people who join our team across a range of positions – from recruiting, sales and delivery to corporate roles. As part of our team, employees have the opportunity for long-term career success, where hard work is rewarded and the potential for growth is limitless.

Established in 1997, Aston Carter is a leading staffing and consulting firm, providing high-caliber talent and premium services to more than 7,000 companies across North America. Spanning four continents and more than 200 offices, we extend our clients’ capabilities by seeking solvers and delivering solutions to address today’s workforce challenges. For organizations looking for innovative solutions shaped by critical-thinking professionals, visit AstonCarter.com. Aston Carter is a company within Allegis Group, a global leader in talent solutions.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please call 888-237-6835 or email astoncarteraccommodation@astoncarter.com for other accommodation options. However, if you have questions about this position, please contact the Recruiter located at the bottom of the job posting. The Recruiter is the sole point of contact for questions about this position.