CPhT RX Prior Authorization Coord I

Moda Health; Portland (OR); On-site; USD 2,934,000 - 3,301,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Pharmacy benefits

Life insurance

Disability insurance

401K matching

FSA

Employee assistance program

PTO and paid holidays

Job summary

Moda Health in Portland seeks a Pharmacy PA Processor to handle electronic prior authorizations, ensuring data is accurate for claims adjudication. This full-time on-site position requires attention to detail and strong coordination with clinical teams.

Applicants should have one year of PA or technician experience in pharmacy or health plans; a Pharmacy Technician license is required, with CPHT preferred. Excellent Word/Excel skills and ability to learn PBM systems are essential.

Qualifications

• High School diploma or equivalent; college degree preferred.
• Minimum one year of prior authorization or technician experience in pharmacy/health plan.
• State Pharmacy Technician license required; CPHT preferred but not required.
• Ability to interpret benefit contracts, clinical criteria and Moda policies.
• Proficiency with Word and Excel; learn PBM claims processing systems.

Responsibilities

• Enter PAs into multiple systems, track requests and meet timelines.
• Perform first pass assessment and initial determinations on PA requests.
• Interpret formulary coverage and triage to clinical team.
• Interpret contracts and determine actions required for PA requests.
• Resolve formulary issues for members across multiple plans.
• Monitor turnaround time and ensure NCQA timelines are met.
• Communicate PA decisions to providers, members, and internal teams.
• Assist with member appeals, grievances, and documentation.

Education

High School diploma or equivalent

College degree preferred

Pharmacy Technician license

CPhT preferred

Strong Microsoft Office skills (Word, Excel)

Tools

Microsoft Office

Job description

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Let’s do great things, together!

Position Summary

Utilizes the electronic prior authorization (PA) platform to process pharmacy PAs in accordance with clinical criteria and plan benefits while ensuring that the necessary data is inputted into the claims adjudication system for successful claims processing. This is a FT on-site position based in Portland.

Pay Range

$21.30 - $23.96 hourly (depending on experience).

• Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education

• High School diploma or equivalent required. College degree preferred. Equivalent work experience in health care administration, pharmacy, or other health related fields may substitute for the education requirement.
• Minimum one year working experience in a prior authorization or technician role in a pharmacy or health plan.
• State Pharmacy Technician license required for all external applicants. Internal applicants are required to obtain one within six months of hire date. CPhT is preferred but not required.
• Demonstrated critical decision making, ability to interpret benefit contracts, clinical criteria and Moda Health administrative policies.
• Demonstrated working knowledge of medical and pharmaceutical terminology and computer skills including Microsoft Office products (proficiency with Word and Excel). Must be able and willing to learn a third-party real-time interactive PBM claims adjudication system, where great attention to detail is imperative.
• Ability to gain proficiency in Moda internal systems, electronic PA platform and PBM claims processing systems.
• Typing proficiency of 40 wpm on a computer keyboard.
• Willingness to work hours necessary to successfully accomplish assigned tasks.
• Abilities to anticipate needs and multi-task; consistently meet quality and production standards; maintain a high level of confidentiality; project a professional business image; be flexible and adapt to change; handle stress and pressure.
• Sound analytical problem solving, decision making, memory retention, and organizational skills.
• Excellent verbal, written, and interpersonal communication skills including active listening, teamwork, working respectfully with co-workers and members.
• Preference for fast-paced, production-oriented environment.
• Must have the to resolve pharmacy conflicts in a professional manner.
• Ability to come to work on time and daily.

Primary Functions

• Accountable for accurately entering PAs into multiple systems, tracking requests, and meeting timeline requirements for decisions and notifications of decisions to members and providers according to corporate policy and government regulations.
• Responsible for the first pass assessment and evaluation of the PA request prior to higher level review: prepares, assesses, evaluates, and makes initial determination on the PA request with the information received using established criteria.
• Utilizes critical decision-making skills to interpret formulary coverage and reviews PA requests according to coverage criteria and plan benefits. Prepares necessary documentation and triages requests to the clinical team to determine the outcome.
• Interprets contracts (evidence of coverage, handbooks, summary of benefits etc.) and determines actions required.
• Solves pharmacy plan benefit and formulary issues for members of multiple commercial and ACA plans. Must be able to accurately distinguish member benefit plans and determine member eligibility across varying lines of business and according to varying State requirements.
• Screens requests for formulary status (e.g., PA required, non-formulary excluded, quantity limits, etc.).

Monitors pharmacy turn-around time deadlines and takes action to ensure required timelines are met. Adheres to timelines set forth by the National Committee for Quality Assurance (NCQA)

Determines whether additional information is needed from the requesting provider’s office and triages the request to the Rx Assistants.

Communicates PA decisions and ensures appropriate feedback and follow-up for all PA requests via electronic interface, fax, telephone, and/or email to requesting providers, members, pharmacies, and internal departments within the promissory timeframes.

Supports, tracks, maintains and ensures data and documentation for member appeals, grievances and complaints are provided within necessary timelines.

Interacts with providers and provider offices via electronic interface, fax and/or telephone to gather complete, accurate information to adequately process a PA.

Acts as an active team player, responding to the needs of the unit as they arise.

Other duties as assigned

Working Conditions & Contact With Others

• Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.
• Internally with own department, primarily with the Clinical team, Operations and Customer Service; as needed with Appeals, Healthcare Services, Marketing, and Medicare Programs. Externally with Moda members, PBM vendor, providers, provider offices, pharmacists, and pharmacies.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training.

For more information regarding accommodations please direct your questions to Kristy Nehler and Danielle Baker via our [e-mail] email.