Prior Authorization Specialist

Lensa; United States; Remote; USD 49,000 - 150,000; Full time

Job summary

Lensa seeks a Prior Authorization Specialist for a fully remote, 12-month contract role. The specialist will handle in-bound calls from providers and assist with prior authorization processes, ensuring compliance and quality standards are met. Ideal candidates should have experience in customer service and prior authorization, with a focus on detail and communication.

Qualifications

• 0-3 years in a customer service or call center environment managing 75 calls/day.
• Six months of PBM/pharmaceutical related work strongly desired.
• At least two years of general business experience that includes problem resolution and customer service.

Responsibilities

• Provide professional and courteous phone assistance through the criteria based prior authorization process.
• Maintain complete, timely and accurate documentation of reviews.
• Ensure compliance with CMS and department standards.

Skills

Prior Authorization

Medicare and Medicaid

Call handling experience

Education

High School diploma or GED

Job description

Lensa is a U.S. career site that helps job seekers discover job opportunities. We are not a staffing firm or agency. We promote jobs on behalf of our clients, which include employers, recruitment agencies, and marketing partners.

Job Title: Prior Authorization Specialist

Location: Fully remote

Duration: 12 months contract

Job Description

• Prior Authorization Specialist takes in-bound calls from providers, pharmacies, members, etc providing professional and courteous phone assistance to all callers through the criteria based prior authorization process.
• Maintains complete, timely and accurate documentation of reviews.
• Transfers all clinical questions, escalations and judgement calls to the pharmacist team.
• The Rep I, Clinical Services will also assist with other duties as needed to include but not limited to: outbound calls, reviewing and processing Prior Auth’s received via fax and ePA, monitoring and responding to inquiries via department mailboxes and other duties as assigned by the leadership team.
• Work closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business and in accordance with Medicare Part D CMS Regulations.
• Must apply information provided through multiple channels to the plan criteria defined through work instruction.
• Research and conduct outreach via phone to requesting providers to obtain additional information to process coverage requests and complete all necessary actions to close cases.
• Responsible for research and correction of any issues found in the overall process.
• Phone assistance is required to initiate and/or resolve coverage requests.
• Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed.
• Must maintain compliance at all times with CMS and department standards.
• Position requires schedule flexibility and additional cross training to learn all lines of business.
• Flexibility for movement to different parts of the business to support volume where needed.
  
  

Responsibilities

• Utilizing multiple software systems to complete Medicare appeals case reviews
• Meeting or exceeding government mandated timelines
• Complying with turnaround time, productivity and quality standards
• Conveying resolution to beneficiary or provider via direct communication and professional correspondence
• Acquiring and maintaining basic knowledge of relevant and changing Med D guidance
• Effectively manage work volume by handling inbound calls/fax/ePA requests utilizing appropriate courteous and professional behavior based upon established standards.
• Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.
• Communication with other internal groups regarding determination status and results (seniors, pharmacists, appeals, etc).
• Identify and elevate clinical inquiries to the pharmacist team as appropriate.
  
  

Experience

• 0-3 years in a customer service or call center environment managing 75 calls/day.
• Six months of PBM/pharmaceutical related work strongly desired
• At least two years of general business experience that includes problem resolution, business writing, quality improvement and customer service
  
  

Skills

• Prior Authorization
• Medicare and Medicaid
• Call handling experience.
  
  

Education

• High School diploma or GED
  
  

About US Tech Solutions

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com (http://www.ustechsolutionsinc.com) .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

If you have questions about this posting, please contact [e-mail]

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Other

• Industries

  IT Services and IT Consulting

Referrals increase your chances of interviewing at Lensa by 2x

Sign in to set job alerts for “Specialist” roles.

United States $82,000.00-$130,000.00 2 weeks ago

United States $130,000.00-$150,000.00 6 days ago

United States $88,800.00-$133,200.00 1 week ago

New York, NY $49,500.00-$71,500.00 1 month ago

Atlanta, GA $49,500.00-$71,500.00 1 month ago

Philadelphia, PA $49,500.00-$71,500.00 1 month ago

Tampa, FL $49,500.00-$71,500.00 1 month ago

Orlando, FL $49,500.00-$71,500.00 1 month ago

Memphis, TN $49,500.00-$71,500.00 1 month ago

United States $53,000.00-$60,000.00 1 day ago

Trenton, NJ $49,500.00-$71,500.00 1 month ago

Miramar, FL $49,500.00-$71,500.00 1 month ago

Denver, CO $49,500.00-$71,500.00 1 month ago

Customer Experience Specialist - Corporate Payment Services

Columbia, SC $49,500.00-$71,500.00 1 month ago

United States $79,100.00-$158,200.00 1 week ago

Senior Payroll Specialist, U.S. (Remote)

United States $80,000.00-$90,000.00 2 weeks ago

Arlington, VA $49,500.00-$71,500.00 1 month ago

Rochester, NY $49,500.00-$71,500.00 1 month ago

Detroit, MI $49,500.00-$71,500.00 1 month ago

Arlington, VA $49,500.00-$71,500.00 1 month ago

United States $79,100.00-$158,200.00 1 week ago

Worcester, MA $49,500.00-$71,500.00 1 month ago

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.