Prior Authorization Guidelines Specialist I (CPhT)

MedImpact Healthcare Systems, Inc.; San Diego (CA); On-site; USD 31,684 - 52,348; Full time

Benefits offered by this job

Medical / Dental / Vision / Wellness

Paid Time Off / Holidays

Incentive Compensation

401K with Company match

Life and Disability Insurance

Tuition Reimbursement

Employee Referral Bonus

Job summary

MedImpact Healthcare Systems, Inc. is seeking a professional to provide technical and administrative support to the Fee-For-Service Medicaid department.

You will collaborate with Clinical Program Managers, Clinical PA Guidelines staff, and Drug Information teams to create Medication Request Guidelines, MRFs, and electronic rules, and you will support PA implementations and Prior Authorization processing. This role requires handling client communications, ensuring timely distribution of

Qualifications

• AA degree and 2+ years’ related experience.
• Strong MS Office and database skills.
• Pharmacy license or CPhT certification.

Responsibilities

• Create and maintain PA Guidelines documents (content management, file maintenance and archiving).
• Provide technical and administrative support to the Clinical Program Manager and PA guidelines teams with the Medication Request process.
• Communicate with clients to obtain authorization of final documents and ensure distribution to appropriate departments.
• Direct the timely communication of information to relevant departments for Medical Exception/Prior Authorization and Formulations.
• Manage QA for guidelines prior to implementation and distribution to clients or internal users.
• Serve as SME on PA guideline processes and respond to questions from internal and external customers.

Skills

Communication skills

Detail oriented

Customer service

Time management

Education

AA with 2+ years’ experience

Tools

MS Office (Word, Excel, Outlook)

Windows-based databases

Job description

Exemption Status

United States of America (Non-Exempt)

$22.99 - $30.35 - $37.71

“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!

Summary

Job Description

Provide technical and administrative support to the Fee-For-Service (FFS) Medicaid department, primarily by working directly with the client teams, Clinical Program Managers (CPMs), Clinical Specialists, and Clinical PA Guidelines/Drug Information Management staff to create and support the appropriate administration of pharmacy information to include Medication Request Guidelines, Medication Request Forms (MRFs), and electronic rules. Support PA in researching PA-related tasks, PA Implementation and perform Prior Authorization processing as needed.

Essential Duties and Responsibilities

• Create and maintain PA Guidelines documents (content management, file maintenance and archiving, coding and linking in on-line electronic systems).


• Provide technical and administrative support to the Clinical Program Manager, Clinical PA Guidelines, Drug Information and PA&UM staffs with the Medication Request process to include formatting, verifying and testing of client Medication Request Guidelines (custom and standard) and formatting/development of Medication Request Forms (MRFs) and electronic rules.


• Communicate with clients to obtain client authorization of final documents and ensure timely distribution of documentation to appropriate departments.


• Direct the timely and accurate communication of information to appropriate department staff to include: Medical Exception/Prior Authorization; Medication Request Forms (MRFs); Clinical Document Maintenance, electronic prior authorization and formulary management rules, and associated tools and programs.


• Manage review/QA process for medical exception/prior authorization guidelines prior to implementation and distribution to clients or internal users.


• Serve as subject matter expert on processes related to the procedures necessary to ensure effective maintenance of MedImpact Prior Authorization program, and as a resource for PA guidelines related questions and/or inquiries from both internal and external customers

Supervisory Responsibilities

No supervisory responsibilities

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education And/or Experience

CL05 - AA and 2+ years’ 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 an U.S. State or Territory). Maintains a current Pharmacy License and/or CPhT certification without restriction.

Other Skills And Abilities

• Demonstrates ability to appear for work on time, follow directions from a supervisor, interact well with co-workers, understand and follow work rules and procedures, comply with corporate policies, goals and objectives, accept constructive criticism, establish goals and objectives, and exhibit initiative and commitment.


• Understanding of managed pharmacy benefit concepts including formularies, prior authorizations, edits, and claim adjudication. Self-starter with the ability to work independently and as part of a team. Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Reasoning Ability

• Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.

Mathematical Skills

• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Language Skills

• Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence.


• Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

Competencies

• Composure


• Decision Quality


• Organizational Agility


• Problem Solving


• Customer Focus


• Drive for Results


• Peer Relations


• Time Management


• Dealing with Ambiguity


• Learning on the Fly


• Political Savvy

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 accommodation 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 25 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 accommodation may be made to enable individuals with disabilities to perform the essential functions. This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. 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

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

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.