Pharmacy Prior Authorization Specialist- - FT(Days)

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

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One! We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid‑South. Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.

A Brief Overview

Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

What you will do

• 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.

Education/Formal Training Requirements

• Required - High School Diploma or Equivalent
• Work Experience Requirements Required - Pharmacy (clinical, hospital, outpatient, or specialty) 3-5 years

Licenses and Certifications Requirements

• Required - Pharmacy Technician - Tennessee - Tennessee Board of Pharmacy
• Required - Certified Pharmacy Technician - Pharmacy Technician Certification Board
• Preferred - Certified Pharmacy Technician- ExCPT - National Healthcareer Association
• Preferred - Pharmacy Technician - Mississippi - Mississippi Board of Pharmacy

Knowledge, Skills and Abilities

• Basic understanding of prescription processing flow.
• Expertise in utiliizing EMRs to document clinical critieria required for third party approval.
• Knowledgeable of medical terminology, drug nomenclature, symbols and abbreviations associated with pharmacy practice.
• Strong attention to detail and critical thinking skills.
• Ability to speak and communicate effectively with patients, associates, and other health professionals.
• Ability to diagnose a situation and make recommendations on how to resolve problems.
• Experience with a computerized healthcare information system required.
• Familiarity with fundamental Microsoft Word software.
• Excellent verbal and written communication skills.

Supervision Provided by this Position

There are no lead or supervisory responsibilities assigned to this position.

Physical Demands

The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion. Must have good balance and coordination.

The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.

The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.

The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative.

Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity.

Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community. Within any role at Methodist Le Bonheur, you can play a rewarding and fulfilling part in helping us provide high-quality, innovative and compassionate care to the people of Memphis and the Mid‑South.

Our goal is to improve every life we touch, including our Associates. For over a century, we’ve served the health care needs of the people of Memphis and the Mid‑South, and we value the dedicated individuals who play such a crucial role in helping us fulfill our mission. With Methodist Le Bonheur, you’ll be recognized and rewarded, treated with respect and given many opportunities to learn, grow and build a fulfilling career. Because we’re not at our best until you are at yours.