Prior Authorization Coordinator, Pharmacy Buisness office, 40hr, Day

UMass Memorial Health; Worcester (MA); On-site; USD 29,000 - 40,000; Full time

Job summary

UMass Memorial Health in Worcester, MA is seeking a dedicated Prior Authorization Specialist to support general and oncology infusion clinics. You will review medical necessity, coordinate with insurers, and ensure timely authorizations to maintain uninterrupted patient care.

Working Monday–Friday, 8:00 AM–4:30 PM, you will collaborate with Insurance Verification, Central Billing, and other departments, maintain records, and contribute to our commitment to quality and patient service.

Qualifications

• 2-3 years of medical secretarial/administrative support experience.
• Proficiency with Microsoft Office and internet research.
• Strong customer service and teamwork skills.

Responsibilities

• Completes prior authorization review for all general and oncology infusions; researching medical necessity in reference to patient diagnosis and treatment plan utilizing appropriate compendiums and insurer policies.
• Works with multiple insurance carriers/vendors and keeps current with any and all changes as they relate to prior authorization.
• Communicates / interacts with specific divisions regarding approved or denied prior authorizations. Communicates with Insurance Verification, the Central Billing Office and other Departments in order to resolve prior authorization issues.
• Manages the "Incoming Patient Report" ensuring appropriate Prior Authorizations are in place.
• Utilizing appropriate databases, tracking mechanisms, and tools, manages all prior authorization renewals to assure no lapse in medication treatment coverage.
• Coordinates process for authorization using defined best practices.
• Participates in the management of a shared database which holds all prior authorization numbers and makes edits as needed.
• Assists in the maintenance of the Prior Authorization Best Practices manual which includes prior authorization requirement changes made by the insurance carriers and makes recommendations for changes.
• Performs weekly prior authorization audit to ensure accurate billing and resolves issues that arise.
• Produces correspondence, reports, memos, etc. as required
• Sets up and maintains confidential, sensitive files and records for multiple functions, academic materials, medical records, etc. ensuring efficient retrieval of information. Coordinates retrieval of medical records.
• Ensures adequate inventory of office supplies and basic maintenance of office equipment.
• Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
• Ensures compliance with health and safety requirements and with regulatory agencies such as DPH, etc.

Skills

Microsoft Office

Customer service

Teamwork

Education

High School diploma

Tools

All Scripts

IDX

Job description

Are you a current UMass Memorial Health caregiver?

Exemption Status: Non-Exempt

Hiring Range: $20.94 - $29.27

(based on a full time schedule of 40 hours per week).

Please note that the final offer will vary based on scheduled hours. Compensation for part-time or reduced schedules will be prorated based on scheduled weekly hours, experience, skills, qualifications, and internal equity considerations.

Schedule Details: Monday through Friday

Scheduled Hours: 8:00AM -4:30PM

Shift: 1 - Day Shift, 8 Hours (United States of America)

Hours: 40

Cost Center: 10020 - 3851 Pharmacy Business Office

Union: SHARE (State Healthcare and Research Employees)

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver - regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

Obtains authorization numbers from insurance companies, reviews all prior authorization requests for medical necessity, and determines appropriate benefit coverage for all general and oncology infusion clinics supported by the Pharmacy Business office.

Major Responsibilities:

• Completes prior authorization review for all general and oncology infusions; researching medical necessity in reference to patient diagnosis and treatment plan utilizing appropriate compendiums and insurer policies.
• Works with multiple insurance carriers/vendors and keeps current with any and all changes as they relate to prior authorization.
• Communicates / interacts with specific divisions regarding approved or denied prior authorizations. Communicates with Insurance Verification, the Central Billing Office and other Departments in order to resolve prior authorization issues.
• Manages the "Incoming Patient Report" ensuring appropriate Prior Authorizations are in place.
• Utilizing appropriate databases, tracking mechanisms, and tools, manages all prior authorization renewals to assure no lapse in medication treatment coverage.
• Coordinates process for authorization using defined best practices.
• Participates in the management of a shared database which holds all prior authorization numbers and makes edits as needed.
• Assists in the maintenance of the Prior Authorization Best Practices manual which includes prior authorization requirement changes made by the insurance carriers and makes recommendations for changes.
• Performs weekly prior authorization audit to ensure accurate billing and resolves issues that arise.
• Produces correspondence, reports, memos, etc. as required
• Sets up and maintains confidential, sensitive files and records for multiple functions, academic materials, medical records, etc. ensuring efficient retrieval of information. Coordinates retrieval of medical records.
• Ensures adequate inventory of office supplies and basic maintenance of office equipment.
• Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
• Ensures compliance with health and safety requirements and with regulatory agencies such as DPH, etc.

Position Qualifications:

License/Certification/Education:
Required:

• High School diploma

Experience/Skills:
Required:

• 2-3 years of medical secretarial/administrative support experience.
• Microsoft Office and internet skills required.
• Good customer service skills. Ability to work in a team environment.

Preferred:

• 6 -12 months of prior authorization experience in an infusion setting preferred.
• Prior experience using All Scripts, IDX, preferred.

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Department-specific competencies, including age-specific competencies and their measurements, will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents.

III. Physical Demands and Environmental Conditions:

Work is considered sedentary. Position requires work indoors in a normal office environment.

M-F 8:00AM-4:30PM

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We're striving to make respect a part of everything we do at UMass Memorial Health - for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at [e-mail]. We will make every effort to respond to your request for disability assistance as soon as possible.