Pharmacy Prior Authorization Senior Representative - CarepathRX - Remote

Cigna Healthcare; Clayton (NC); Remote; USD 52,000 - 76,000; Full time

Job summary

The Cigna Group is seeking a Pharmacy Prior Authorization Senior Representative in North Carolina. This role focuses on obtaining initial and renewal authorizations for Specialty Pharmacy and/or Specialty Infusion services, with collaboration from clinicians to support documentation and formulary guidelines.

You will ensure timely follow-up on authorizations, interface with multiple departments, and communicate effectively regarding approvals, denials, and appeals.

Qualifications

• 2+ years of prior authorization, insurance verification or related experience in a healthcare setting.
• Knowledge of medical terminology.
• Knowledge of payer websites, eligibility, and coordination of benefits.
• Knowledge of plan formularies and authorization requirements.
• Knowledge of pharmacy vs medical payers and authorization.
• Proficient computer skills and Microsoft Office products.

Responsibilities

• Obtains initial and renewal authorizations for Specialty Pharmacy and/or Specialty Infusion services.
• Interfaces with clinicians and staff to gather medical documentation per formulary guidelines.
• Ensures authorizations are followed up in a timely manner.
• Notifies patient, prescriber and internal teams about denials or appeals.
• Verifies plan eligibility and processes test claims.
• Calculates units and quantity vs day supply.
• Prioritizes tasks and meets deadlines.
• Responds to chat/email update requests promptly.
• Maintains effective communication channels to relay issues and ideas.
• Works to meet quality standards with reliability and follow-through.

Skills

Team player

Client focus

Customer service

Verbal & written communication

Confidentiality

Attention to detail

Multitasking

Computer literacy

Education

HS diploma or GED

Tools

Windows

MS Office

Outlook

Word

Excel

Job description

The Pharmacy Prior Authorization Senior Representative is responsible for obtaining initial prior authorization and renewal authorizations for Specialty Pharmacy and/or Specialty Infusion services. Collaborates with clinicians regarding supporting medical documentation in accordance with formulary guidelines. Manages the quality review of requested prior authorizations.

Responsibilities

• Obtains initial and renewal authorizations for Specialty Pharmacy and/or Specialty Infusion services from insurance companies via portal, phone, fax.
• Ensures initial and renewal authorizations are followed up on in a timely manner.
• Interface with other departments and identify medical documentation in support of prior authorization requests.
• Notifies the patient, prescriber and internal teams of insurance denial/appeals process.
• Confirms plan eligibility and processes test claims.
• Calculates required units and quantity vs day supply.
• Prioritizes and completes assigned tasks on schedule.
• Responds to chat/email update requests timely.
• Utilizes appropriate communication lines in relaying problems, concerns, questions, and ideas.
• Demonstrates the ability to work effectively and maintain expected productivity.
• Meets quality standards, shows pride in performance, and demonstrates reliability and follow-through on all assigned tasks.
• Demonstrates ability to communicate effectively and express ideas clearly.
• Performs in accordance with system-wide competencies/behaviors.
• Performs other duties as assigned.

Skills & Abilities

• Team player.
• Gives high priority to client satisfaction and customer needs. Maintains confidentiality of patient information.
• Provides customer service to all internal and external customers.
• Good verbal and written communication skills.
• Computer literate, with the ability to utilize standard software applications including Windows and MS
• Office Suite (Outlook, Word, and Excel).
• Good organizational skills with attention to detail and ability to multitask.

Requirements

• HS diploma or GED required.
• 2+ years of prior authorization, insurance verification or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required.
• Knowledge of medical terminology required.
• Knowledge of payer websites, eligibility, and coordination of benefits required.
• Knowledge of plan formularies and authorization requirements required.
• Knowledge of pharmacy vs medical payers and authorization required.
• Proficient computer skills and Microsoft Office Products required.

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

About The Cigna Group

Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you need a reasonable accommodation to complete the online application process, please email for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.