Prior Authorization Representative

Orsini Healthcare; Elk Grove Village (IL); Hybrid; USD 26,000 - 37,000; Full time

Benefits offered by this job

Medical, Dental, Vision coverage

401(k) with employer match

Insurance options

PTO & holidays

Tuition reimbursement

Job summary

Orsini Rare Disease Pharmacy Solutions is seeking a detail-oriented Prior Authorization Representative to join our Benefits Verification Team in Elk Grove Village, IL. This hybrid role requires 2-3 days in office and involves validating insurance plans, interpreting clinical documentation, and initiating prior authorizations to ensure timely patient access to therapies.

You will read prescriptions, convert them into authorizations, and communicate with physician offices and payers.

Qualifications

• Experience with Major Medical Insurance.
• Knowledge of Pharmacy Benefit.
• Knowledge of HCPC Codes (J-Codes).
• Knowledge of ICD-10 Codes (Diagnoses Codes).
• Familiar with medical documentation such as H&P’s, Genetic testing, etc.
• Ability to read prescriptions.
• Ability to convert a prescription into an authorization request based on payer requirements.
• Ability to interpret medical policies.
• Proficiency in Microsoft Office (including Excel/TEAMS).

Responsibilities

• Contact plans (PBM or Major Medical) to validate requests sent from BV.
• Contact physician offices to obtain current prescriptions and required clinical documentation.
• Validate that received clinical documentation meets plan requirements.
• Initiate prior authorizations through CoverMyMeds and follow up on all pending PAs within 48 hours.
• Respond to urgent requests from the Patient Care Coordinator Team or Program Manager in a timely manner.
• Obtain approval and denial letters.
• Submit new and re-authorizations through the Complex audit process.
• Initiate re-authorizations 30 days prior to expiration.
• Ability to meet daily KPIs in a fast-paced environment.
• Strong attention to detail with willingness to go the extra mile.
• Ability to multitask and manage priorities effectively.
• Flexibility to work overtime as needed.
• Other duties as assigned.

Skills

Major Medical Insurance

Pharmacy Benefit

HCPCS/J-Codes

ICD-10 Codes

Prescription reading

Authorization requests

Medical policy interpretation

Microsoft Office

Data entry

Multitasking

Organizational skills

Job description

Careers with real impact.

Every role at Orsini moves a patient closer to life-changing therapy. We partner with biopharma innovators, healthcare providers, and payers to make access simple, compassionate, and reliable - so no patient is left behind. Make your next role matter.

ABOUT ORSINI

Providing compassionate care since 1987, Orsini is a leader in rare disease and gene therapy pharmacy solutions, built to simplify how patients connect to advanced medicines. Through our comprehensive commercialization solutions including a nationwide specialty pharmacy, patient services hub, home infusion and nursing network, and third-party logistics provider, we work with biopharma, providers, and payors to ensure No Patient is Left Behind™

OUR MISSION

Orsini is on a mission to be the essential partner for biopharma innovators, healthcare providers, and payers to support patients and their families in accessing revolutionary treatments for rare diseases. Through our integrated portfolio of services, we seek to pioneer comprehensive solutions that simplify how patients connect to advanced therapies while providing holistic, compassionate care so that No Patient is Left Behind™.

CORE VALUES

At the heart of our company culture, the Orsini LIVE IT Core Values serve as guiding principles that shape how we interact with each other and those we serve. These values are the driving force behind our commitment to excellence, collaboration, and genuine care in every aspect of our work.

COMPENSATION & LOCATION

The compensation range for this role is $23.00/hour.

This a hybrid position based out of our Elk Grove Village, Illinois location requires 2-3 days in office. Travel to other locations may occur, although minimal.

POSITION SUMMARY

This position will work closely with the Benefits Verification Team tovalidatepatient’sinsurance plans,prescriptionsand eligibility. Job responsibilities includeabilityto read prescriptions, convert prescriptions intoauthorizationsand interpret medical policies. Prior Authorization Representativesare responsible forcontactingphysician’soffices tovalidateprescriptions, obtain clinical documentationandinitiateprior authorizations through insurance plans.

ESSENTIAL DUTIES

• Contact plans (PBM or Major Medical) to validate requests sent from BV
• Contact physician offices to obtain current prescriptions and required clinical documentation
• Validate that received clinical documentation meets plan requirements
• Initiate prior authorizations through CoverMyMeds and follow up on all pending PAs within 48 hours
• Respond to urgent requests from the Patient Care Coordinator Team or Program Manager in a timely manner
• Obtain approval and denial letters
• Submit new and re-authorizations through the Complex audit process
• Initiate re-authorizations 30 days prior to expiration
• Ability to meet daily key performance indicators (KPIs) in a fast-paced environment
• Strong attention to detail with a willingness to go the extra mile
• Ability to multitask and manage priorities effectively
• Flexibility to work overtime as needed
• Other duties as assigned

Disclaimer: The information written in this job descriptionindicatesthe general nature and level of work to be performed. This job description is not designed tocontainor be interpreted astotally comprehensiveof every job duty, responsibility, or qualification required by an employee assigned to this job. While employed in this position, an employee maybe requiredto perform other assignments not listed in this job description.

KNOWLEDGE, SKILLS, AND TRAINING

• Experience with Major Medical Insurance.
• Knowledge of Pharmacy Benefit.
• Knowledge of HCPC Codes (J-Codes).
• Knowledge of ICD-10 Codes (Diagnoses Codes).
• Familiar with medical documentation such as H&P’s, Genetic testing,etc.
• Ability to read prescriptions.
• Ability to convert a prescription into an authorization request based on payer requirements.
• Ability to interpret medical policies.
• Proficiency in Microsoft Office (including Excel/TEAMS)
• Strong data entry and quality assurance skills with attention to detail
• Ability to multitask in a fast-paced environment
• Self-starter with strong organizational skills

EMPLOYEE BENEFITS

• Medical Coverage, Dental, and Vision Coverage
• 401(k) with employer match
• Accident and Critical Illness coverage
• Company-paid life insurance options
• Generous PTO, paid holidays, and floating holidays
• Tuition reimbursement program.

Equal Employment Opportunity

Orsini Rare Disease Pharmacy Solutions is committed to the principle of Equal Employment Opportunity for all employees and applicants. It is our policy to ensure that both current and prospective employees are afforded equal employment opportunity without consideration of race, religious creed, color, national origin, nationality, ancestry, age, sex, marital status, sexual orientation, or present or past disability (unless the nature and extent of the disability precludes performance of the essential functions of the job with or without a reasonable accommodation) in accordance with local, state and federal laws.

Americans with Disabilities Act

Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

E-Verify Participation Notice

We participate in the federal E-Verify program to confirm the identity and employment eligibility of all newly hired employees.

All offers of employment are contingent upon the successful completion of Form I-9 and verification through the E-Verify system.

For more information about E-Verify, please review the official notices below:

E-Verify Participation Poster (English & Spanish):
https://www.e-verify.gov/sites/default/files/everify/posters/EVerifyParticipationPoster.pdf

Right to Work Poster (English & Spanish):
https://www.e-verify.gov/sites/default/files/everify/posters/IER_RightToWorkPoster.pdf