Pharmacy Prior Authorization Specialist

UPMC; Bridgeville (Allegheny County); On-site; USD 55,000 - 85,000; Full time

Benefits offered by this job

Generous benefits package

Total rewards package

Career growth opportunities

Job summary

UPMC Rx Partners is seeking a full-time Pharmacy Clinical Review Specialist to oversee administrative and system processes related to pharmacy prior authorizations. You will conduct first-line clinical reviews for Community Provider Services to ensure payment and collaborate with clinicians to obtain supporting documentation.

Daylight hours with a rotating Saturday shift approximately every five weeks. UPMC offers a generous benefits package, an expansive total rewards package, and opportunities

Qualifications

• HS diploma or equivalent required.
• Minimum 2 years of Pharmacy claims or Pharmacy technician experience in a physician practice, ancillary provider, or other healthcare setting.
• Experience in pharmacy claims processing systems required.
• Knowledge of retail pharmacy processes and LTC billing functions preferred.
• Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines and prescription drug utilization management.
• Customer service experience with communication via telephone, e-mail and face to face required.

Responsibilities

• Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.
• Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
• Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards.
• Perform peer reviews of prior authorization requests.
• Maintain or exceed designated quality and production standards.
• Develop and maintain the pre-logic and clinical criteria in support of the prior authorization determination process.
• Interface with other departments and identify medical documentation in support of prior authorization requests.
• Participates in the monthly billing process and assist with collection of delinquent accounts.
• Act as a conduit of information between the Pharmacy, operations and clinical and the facility staff.
• Report and respond to elevate issues and concerns in a within twenty-four hours.
• Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business.

Skills

Pharmacy claims

MS Office

Customer service

Multichannel communication

Prior authorization

Pharmacy terminology

Education

High school diploma or equivalent

Tools

Pharmacy claims software

MS Office

Job description

UPMC Rx Partners is seeking a full-time Pharmacy Clinical Review Specialist to oversee administrative and system processes related to pharmacy prior authorizations. You will conduct first-line clinical reviews for Community Provider Services to ensure payment and collaborate with clinicians to obtain supporting documentation.

Daylight hours with a rotating Saturday shift approximately every five weeks. UPMC offers a generous benefits package, an expansive total rewards package, and opportunities