Prior Authorization & Referral Coordinator

Providence Health Plan Group; Seattle, Northern (WA, KY); Hybrid; USD 32,000 - 50,000; Full time

Job summary

Providence Swedish is seeking a Prior Authorization Specialist to facilitate processing of medication prior authorizations for clinic patients in Seattle. You will liaise with physicians, pharmacies and insurance carriers to ensure timely, accurate determinations and support the medical review process.

Responsibilities include handling authorizations, appeals, audits and training; using insurer portals; triaging calls; and gathering documentation to verify medical necessity while ensuring

Qualifications

• 2 years experience in a medical clinic or managed care/health insurance plan within the past 2 years.
• Bachelor's degree in a related field.
• 2 years experience in an area such as prior authorizations, medical audits, appeals or delegation.
• 1 year Epic software experience.

Responsibilities

• Demonstrates proficiency in core functions of one or more medication prior authorization areas, including prior authorizations, appeals, audits, and training.
• Serves as a resource for the Prior Authorization Service by providing technical assistance to clinic staff and physicians regarding patient coverage, authorization guidelines and procedures, claims research, and departmental operating procedures.
• Utilizes and navigates various insurance company websites to obtain medication prior authorization requirements and protocols.
• Receives, triages, and responds appropriately to phone calls from pharmacies and clinics seeking assistance.
• Processes all documentation and forms related to medication prior authorizations, including submissions via fax, online portals, and telephone.
• Verifies member eligibility as necessary to process medication prior authorizations and collaborates with clinic staff and pharmacies to obtain required information.
• Reviews patient charts to gather documentation supporting the medical necessity of requested medications. Completes prior authorization requests by incorporating relevant clinical information and benefit details, including plan limitations and exclusions, to support the medical review process.
• Contacts clinics to obtain additional clinical information, such as chart notes and diagnostic results, as needed to facilitate the medical review process.

Education

Bachelor's degree in a related field

Job description

Providence Swedish is seeking a Prior Authorization Specialist to facilitate processing of medication prior authorizations for clinic patients in Seattle. You will liaise with physicians, pharmacies and insurance carriers to ensure timely, accurate determinations and support the medical review process.

Responsibilities include handling authorizations, appeals, audits and training; using insurer portals; triaging calls; and gathering documentation to verify medical necessity while ensuring