Pharmacy Prior Authorization Pro: Fast, Accurate Approvals

1200 MH-Memphis Hospitals; Indianapolis (IN); On-site; USD 40,000 - 60,000; Full time

Job summary

Methodist Le Bonheur Healthcare in Memphis seeks a Pharmacy Technician specializing in precertification of prescription medications for inpatient and outpatient services. You will ensure documentation meets insurer guidelines for medical necessity and payment, and you will verify orders and coordinate prior authorization.

Requires 3–5 years in pharmacy, High School Diploma, Tennessee Pharmacy Technician license, and Certification Board credentials; experience with EMR systems and Microsoft Word

Qualifications

• Responsible for precertification of eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity.
• Ensures medical documentation is sufficient to meet insurer guidelines for medical necessity documentation and procedure payment.
• Reviews clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of prescription medications.
• Assists with patient assistance and grant coordination for Patients for outpatient pharmacies from designated areas.
• Proactively analyzes information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines.
• Verifies physician orders are accurate.
• Determines CPT, HCPCS and ICD‑10 codes for proper Prior Authorization.
• Contacts insurance companies and third party administrators to gather information and organize work‑flow based on the requested procedure.
• Collects, reads and interprets medical documentation to determine if the appropriate clinical information has been provided for insurance reimbursement and proper charge capture.
• Serves as primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines.
• Establishes and maintains rapport with providers as well as ongoing education of providers concerning protocols for pre‑certification.
• Communicates information and acts as a resource to Patient Access, Case Management, and others in regard to contract guidelines and pre‑certification requirements.
• Performs research regarding denials or problematic accounts as necessary.
• Works to identify trends and root cause of issues and recommend resolutions for future processes.

Responsibilities

• Precertification of prescription medications for inpatient and outpatient services based on plan documents and medical necessity.
• Ensure documentation meets insurer guidelines for medical necessity and payment.
• Review clinical information from providers to assess necessity and appropriateness of medication use.
• Assist patient assistance and grant coordination for outpatient pharmacies.
• Analyze provider submissions to determine timely medical necessity decisions.
• Verify accuracy of physician orders.
• Assign CPT, HCPCS and ICD‑10 codes for Prior Authorization.
• Contact insurers and third party admins to gather information and organize workflow.
• Read and interpret medical documentation for reimbursement and charge capture.
• Serve as primary contact with physicians for clinical documentation.

Skills

Prescription processing

EMR documentation

Medical terminology

Attention to detail

Communication skills

Problem solving

Education

High School Diploma or Equivalent

Tools

EMR systems

Microsoft Word

Job description

Methodist Le Bonheur Healthcare in Memphis seeks a Pharmacy Technician specializing in precertification of prescription medications for inpatient and outpatient services. You will ensure documentation meets insurer guidelines for medical necessity and payment, and you will verify orders and coordinate prior authorization.

Requires 3–5 years in pharmacy, High School Diploma, Tennessee Pharmacy Technician license, and Certification Board credentials; experience with EMR systems and Microsoft Word