Prior Authorization Coordinator

Independent Health; United States; Hybrid; USD 25,000 - 36,000; Full time

Benefits offered by this job

Health benefits

Growth culture

Job summary

Independent Health is seeking a Prior Authorization Coordinator to facilitate logging and follow-up on prior authorizations, appeals, reimbursements and grievances to ensure timely resolution. You will work to meet regulatory requirements and support the Pharmacy Benefit Dimensions across lines of business.

The role requires a high school diploma or GED with preferred associate degree, and 2+ years of pharmacy or health insurance operations experience.

Qualifications

• High school diploma or GED required.
• Associates degree preferred.
• Two (2) years of experience in pharmacy or health insurance operations required OR one (1) year of experience as a temporary associate in the Prior Authorization Coordinator role or Prior Authorization department.
• Pharmacy experience strongly preferred.
• General knowledge of drug names, therapeutic categories, dosage forms, manufacturers and packaging preferred.
• Familiarity with HMO concept.
• Experience with pharmacy on-line system preferred.
• Written and verbal communication skills.
• Excellent organizational and time management skills.
• Excellent ability to absorb new concepts and adapt to a changing environment.
• Demonstration of math aptitude for purposes of calculating simple drug requirements when given dose and price calculations.
• Proven examples of displaying the PBD values: Trusted Advisor, Innovative, Excellence, Guardianship, Dedication and Caring.

Responsibilities

• Assist Clinical Review Pharmacist in making appropriate decisions by verifying member and provider eligibility and filing requests into the correct member folder according to set standards.
• Enter data and ensure complete accuracy on all statistics by logging prior authorization requests into pharmacy systems according to set standards.
• Complete the requests by entering override into the appropriate pharmacy system and updating all information in required documentation systems according to set standards.
• May also include transcribing Medical Director decision into systems.
• As volume dictates, timely and accurately complete various reports, reimbursement requests, IRO and review of vendor emails/reports as assigned by the Supervisor.
• Facilitate follow-up phone calls to members and providers for clinical approvals and denials according to set standards.
• Initiate outbound telephone calls to members/physicians regarding decisions within all regulatory time frame requirements.
• Answer and provide resolution to provider and internal callers regarding formulary/prior authorization questions for all lines of business.
• Log all calls into call documentation systems.
• Research and respond to escalated and complex inquiries regarding Pharmacy questions or concerns.
• Ensure that all callers obtain accurate and up-to-date information on policies and procedures and communicate a successful resolution to inquiries.
• Provide callbacks when necessary.
• Provide support for all required letters within the required timeframes.
• Fax prior authorization requests including requests for additional information and completed requests.
• Copy and mail completed requests and related documents.
• Prepare completed requests for scanning into documentation systems.
• Maintain proper storage of all files, in accordance with the corporate retention policy.

Skills

Communication skills

Organization & time management

Adaptability

Problem solving

Math aptitude

Pharmacy/health insurance knowledge

Pharmacy systems familiarity

Education

High school diploma or GED

Associates degree preferred

Tools

Pharmacy on-line system

Documentation systems

Fax/communication tools

Job description

FIND YOUR FUTURE We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.

Overview The Prior Authorization Coordinator will facilitate the logging in and out of all prior authorization, appeal, reimbursement and grievance requests, and follow-up on requests to ensure that all are resolved and completed in a timely manner. The coordinator will ensure that all steps involved with the process are completed and all regulatory requirements are met or exceeded. They will also be responsible for the pharmacy medical exception line to address provider questions regarding the formularies for all lines of business serviced by Pharmacy Benefit Dimensions. The coordinator will also be assigned to provide high quality, diverse administrative support including but not limited to faxing prior authorization requests, completing decision letters by faxing and copying, making decision notification phone calls to members and physicians, filing, and document scanning preparation. Occasional holidays, weekends and overtime will be a requirement of the position.

Qualifications

• High school diploma or GED required.
• Associates degree preferred.
• Two (2) years of experience in pharmacy or health insurance operations required OR one (1) year of experience as a temporary associate in the Prior Authorization Coordinator role or Prior Authorization department required.
• Pharmacy experience strongly preferred.
• General knowledge of drug names, therapeutic categories, dosage forms, manufacturers and packaging preferred.
• Familiarity with HMO concept.
• Experience with pharmacy on-line system preferred.
• Written and verbal communication skills.
• Excellent organizational and time management skills.
• Excellent ability to absorb new concepts and adapt to a changing environment.
• Exhibit creativity and self-motivation, with the ability to effectively solve problems as they arise.
• Demonstration of math aptitude for purposes of calculating simple drug requirements when given dose and price calculations.
• Proven examples of displaying the PBD values: Trusted Advisor, Innovative, Excellence, Guardianship, Dedication and Caring.

Essential Accountabilities

• Assist Clinical Review Pharmacist in making appropriate decisions by verifying member and provider eligibility and filing requests into the correct member folder according to set standards.
• Enter data and ensure complete accuracy on all statistics by logging prior authorization requests into pharmacy systems according to set standards.
• Complete the requests by entering override into the appropriate pharmacy system and updating all information in required documentation systems according to set standards.
• May also include transcribing Medical Director decision into systems.
• As volume dictates, timely and accurately complete various reports, reimbursement requests, IRO and review of vendor emails/reports as assigned by the Supervisor.
• Facilitate follow-up phone calls to members and providers for clinical approvals and denials according to set standards.
• Initiate outbound telephone calls to members/physicians regarding decisions within all regulatory time frame requirements.
• Answer and provide resolution to provider and internal callers regarding formulary/prior authorization questions for all lines of business.
• Log all calls into call documentation systems.
• Research and respond to escalated and complex inquiries regarding Pharmacy questions or concerns.
• Ensure that all callers obtain accurate and up-to-date information on policies and procedures and communicate a successful resolution to inquiries.
• Provide callbacks when necessary.
• Provide support for all required letters within the required timeframes.
• Fax prior authorization requests including requests for additional information and completed requests.
• Copy and mail completed requests and related documents.
• Prepare completed requests for scanning into documentation systems.
• Maintain proper storage of all files, in accordance with the corporate retention policy.

Hiring Compensation Range

Hiring Compensation Range: $22 hourly Compensation may vary based on factors including but not limited to skills, education, location and experience. In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

Immigration or work visa sponsorship will not be provided for this position.

As an Equal Opportunity / Aff ... Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Current Associates must apply internally via the Job Hub.

We are committed to providing reasonable accommodations for qualified individuals with disabilities and disabled veterans. An applicant for employment in need of an accommodation to participate in the application and recruitment process should contact Human Resources at: [e-mail] or Human Resources, 511 Farber Lakes Drive, Williamsville, NY 14221.

Please note, we do not accept unsolicited resumes. We do not accept resumes from headhunters, placement agencies, or other suppliers that have not signed a formal agreement with us.

The Independent Health Family of Companies, headquartered in Buffalo, NY, serves nearly 400,000 members and provides innovative health care products and benefits designed to engage consumers in their health and well-being. Established in 1980, our comprehensive portfolio includes Pharmacy Benefit Dimensions, Reliance Rx, Nova Healthcare Administrators, Care for You and the Independent Health Foundation.

Our culture sets us apart. Our core values drive who we are and the work we do. As a member of our family, you’re part of something special, in your work and in the community. We understand and appreciate that everyone has unique experiences, perspectives and identities which is why we pledge to create a safe space where all people and ideas are welcomed. We are here to continue learning and to generate important dialog. We are committed to doing what matters most - reaching out, working together, and caring for our community. A healthy community benefits everyone who lives in it. You too can be part of making difference in the lives of others, together we achieve so much more.