Prior Authorization Coordinator I

MedImpact Healthcare Systems Inc.; Tempe (AZ); On-site; USD 24,000 - 38,000; Full time

Benefits offered by this job

Medical benefits

Paid time off

401K with company match

Life and disability insurance

Tuition reimbursement

Employee referral bonus

Job summary

MedImpact Healthcare Systems, Inc. in Tempe, AZ is seeking an experienced Prior Authorization Specialist to join the Operations team.

You will process PA requests, use clinical guidelines, and communicate with physicians and pharmacies to obtain or verify information, aiming for timely, accurate determinations according to client requirements. This role requires a GED/HS diploma and at least 1 year of relevant experience; proficiency with MS Office; and the ability to handle high-volume

Qualifications

• GED/HS Diploma and 1+ year experience or equivalent combination of education and experience
• Experience with prior authorization workflows and clinical guidelines
• Strong attention to detail and communication skills

Responsibilities

• Process and finalize Prior Authorization (PA) requests within clients’ turnaround time and Performance Guarantees utilizing guidelines.
• Enter PAs into the system and prioritize requests.
• Check formulary alternatives, review tried and failed medications.
• Utilize drug references and verify the drug being requested is indicated and approved for the condition.
• Document all related information regarding the PA approval or non-approval.
• Respond to requests by faxing status of the PA to the physician or pharmacy
• Conforms to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making.

Skills

Prior Authorization

PA Processing

Customer Service

MS Office

Education

GED/HS Diploma

1+ year experience

Tools

MS Office

Excel

Outlook

Job description

Exemption Status: United States of America (Non-Exempt) $17.69 - $22.55 - $27.41 “Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.” This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description Summary

Works as a member of the Prior Authorization Operations team. Processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments. Uses various business applications to perform analysis, obtain information, and enter prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based upon clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.). Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality. Works under general supervision, relying on instructions, work process guidelines, policies & procedures, and company knowledge/experience to perform the functions of the job. Extent of supervision ranges from close, to moderate, to minimal oversight based upon demonstrated skill and performance levels as defined for the position. This position is part of a three level career path with progression opportunities described in the Core Processing Career Path/Succession Planning Guidelines.

Essential Duties and Responsibilities

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Process and finalize Prior Authorization (PA) requests within clients’ turnaround time and Performance Guarantees utilizing guidelines.
• Enter PAs into the system and prioritize requests.
• Check formulary alternatives, review tried and failed medications.
• Utilize drug references and verify the drug being requested is indicated and approved for the condition.
• Document all related information regarding the PA approval or non-approval.
• Respond to requests by faxing status of the PA to the physician or pharmacy
• Conforms to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making.
• Partners with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing.
• Accountable to achieve prior authorization processing productivity and accuracy standards.
• Analyzes, researches, and resolves prior authorization processing issues as appropriate for experience and career path level, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from team subject matter experts (SME) or supervisor; and referring unique or high dollar requests to supervisor according to guidelines.
• Coordinates notifications to members, physicians, and pharmacies as required to obtain missing information, manage pended requests, and communicate prior authorization determinations.
• Documents prior authorization related information and status.
• Makes outbound calls to obtain information and answer questions about prior authorization status
• Process and finalize Prior Authorization (PA) requests within clients’ turnaround time and Performance Guarantees utilizing guidelines.
• Enter PAs into the system and prioritize requests.
• Check formulary alternatives, review tried and failed medications.
• Utilize drug references and verify the drug being requested is indicated and approved for the condition.
• Document all related information regarding the PA approval or non-approval.
• Respond to requests by faxing status of the PA to the physician or pharmacy
• Conforms to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making.
• Partners with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing.
• Accountable to achieve prior authorization processing productivity and accuracy standards.
• Analyzes, researches, and resolves prior authorization processing issues as appropriate for experience and career path level, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from team subject matter experts (SME) or supervisor; and referring unique or high dollar requests to supervisor according to guidelines.
• Coordinates notifications to members, physicians, and pharmacies as required to obtain missing information, manage pended requests, and communicate prior authorization determinations.
• Documents prior authorization related information and status.
• Makes outbound calls to obtain information and answer questions about prior authorization status.
• Collaborates with MCO and Self-Insured client teams to understand PBM clients’ prior authorization processing requirements and expectations.
• As appropriate for experience and career path level, partners with client teams to complete special prior authorization processing projects and provide accurate, timely, and reliable information to client claim inquiries. (PAC II/II)
• Collaborates with Contact Center Services in resolving prior authorization inquiries Handling Provider, Pharmacy and member calls to complete prior authorization and Peer to Peer requests based on client specific requirements
• Protects and maintains confidentiality and privacy of all prior authorization and member information, including following strict protocols for date stamping and storage/security of prior authorization forms and related information.

Education and/or Experience

GED/HS Diploma and 1+ year experience or equivalent combination of education and experience

Computer Skills

Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs. Experience with Windows based database programs is also required.

Certificates, Licenses, Registrations

Must successfully complete one of the national certification exams OR obtain state licensure (in any U.S. State). Maintains a current Pharmacy Technician License and/or CPhT certification without restriction.

Other Skills and Abilities

None required

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 10 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is a full-time non-exempt position requiring one to be able to work overtime from time to time in order to get the job done. Therefore, one must have the ability to work nights, weekends or on holidays as required. This may be changed at any time to meet the needs of the business. The typical working hours for this position are Monday through Friday from 8:00am to 5:00pm.

Travel

This position requires no travel however attendance may be required at various local conferences and meetings.

The Perks

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

Equal Opportunity Employer

Equal Opportunity Employer, Male/Female/Disabilities/Veterans OSHA/ADA: To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. MedImpact was founded more than three decades ago by a pharmacist and independent drug store owner who saw firsthand how families struggled with the high cost of prescriptions, and how it impacted their lives, financial security, and health. So, he started MedImpact to make prescription benefits understandable and accessible. While we have grown to be one of the leading PBMs in America, we remain as committed to these principles today as we did when it all began.