Job description

Job Description:
This is a remote position and requires the ability to effectively support a work from home environment. Must have the ability to work in a HIPAA compliant work area away from distractions.
You will provide processing and communication of specialty medication prior authorization (PA) requests reviewed by the Specialty Medical Prior Authorization department. Reporting to the Pharmacy Operations Manager, you will work with physician office staff and customer service, admissions and pharmacy operations departments to communicate prior authorization status. You will also oversee fax processing and provide telephone call assistance for prescriber office staff, pharmacies and members based on program criteria.

Responsibilities:

Responsibilities include answering inbound phone calls, processing cases and electronic authorizations, loading authorizations, and making follow-up phone calls utilizing appropriate courteous and professional behavior based upon established standards.
Maintaining complete and accurate, documentation of all necessary information is necessary and will involve computer system data entry, data management, and reporting.
Review criteria-based prior authorizations following policy and procedure.
Provide on-call after hours nurse availability for urgent PA requests.
Provide internal nurse support to the PA team and member services department .
Refer cases not meeting clinical criteria to the Pharmacist and MD team(s).
Shift priorities while exhibiting a high level of urgency with all calls and assignments.
You will work with pharmacists, other clinical colleagues, healthcare professionals and members.
Follow all prior authorization procedures to guarantee an accurate process on each prior authorization.
Train and mentor representatives on the PA team.
Complete other PA assignments as delegated by the PA leadership team.

Experience:

1-3 years of related work experience.

Skills:

Prior Authorization
Utilization Reeview

Education:

High School Diploma or equivalent required
Associate’s or Bachelor’s Degree: Nursing preferred
Other Certificates or Licenses (List): Active LPN license in the state of practice required

Required profile