Prior Authorization Specialist – MED D

US Tech Solutions; United States; Remote; USD 35,000 - 55,000; Full time

Job summary

Join a forward-thinking company as a Prior Authorization Specialist, where you will play a crucial role in assisting providers and members through the prior authorization process. This dynamic position involves handling inbound calls, maintaining accurate documentation, and ensuring compliance with Medicare regulations. You'll collaborate closely with clinical teams, manage inquiries efficiently, and contribute to the overall improvement of service quality. If you have a passion for customer service and a desire to make a difference in healthcare, this is the perfect opportunity for you.

Qualifications

• 0-3 years in customer service or call center managing around 75 calls/day.
• Six months of PBM/pharmaceutical-related work highly desired.

Responsibilities

• Handles inbound calls providing assistance through the prior authorization process.
• Maintains compliance with CMS and departmental standards at all times.
• Researches and conducts outreach to obtain additional information for coverage requests.

Skills

Prior Authorization

Medicare and Medicaid

Call handling experience

Education

High School diploma or GED

Job description

Job Description:

• Prior Authorization Specialist handles inbound calls from providers, pharmacies, members, etc., providing professional and courteous assistance through the criteria-based prior authorization process.
• Maintains complete, timely, and accurate documentation of reviews.
• Transfers all clinical questions, escalations, and judgment calls to the pharmacist team.
• The Rep I, Clinical Services, also assists with other duties as needed, including but not limited to: outbound calls, reviewing and processing prior authorizations received via fax and ePA, monitoring and responding to inquiries via department mailboxes, and other tasks assigned by leadership.
• Works closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business, in accordance with Medicare Part D CMS Regulations.
• Applies information from multiple channels to the plan criteria defined through work instructions.
• Researches and conducts outreach via phone to requesting providers to obtain additional information for coverage requests and completes all necessary actions to close cases.
• Responsible for researching and correcting issues in the overall process.
• Provides phone assistance to initiate and/or resolve coverage requests.
• Escalates issues to Coverage Determinations and Appeals Learning Advocates and management as needed.
• Maintains compliance with CMS and departmental standards at all times.
• Requires schedule flexibility and cross-training to learn all lines of business.
• Supports volume fluctuations by moving to different parts of the business as needed.

Responsibilities:

• Utilizes multiple software systems to complete Medicare appeals case reviews.
• Meets or exceeds government-mandated timelines.
• Complies with turnaround time, productivity, and quality standards.
• Conveys resolutions to beneficiaries or providers via direct communication and professional correspondence.
• Maintains basic knowledge of relevant and evolving Medicare D guidance.
• Manages work volume effectively by handling inbound calls, faxes, and ePA requests courteously and professionally.
• Ensures accuracy of all processed information in compliance with departmental, company, state, and federal requirements.
• Communicates with internal teams regarding determination statuses and results (seniors, pharmacists, appeals, etc.).
• Identifies and escalates clinical inquiries to the pharmacist team appropriately.

Experience:

• 0-3 years in customer service or call center managing around 75 calls/day.
• Six months of PBM/pharmaceutical-related work highly desired.
• At least two years of general business experience involving 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 learn more, visit www.ustechsolutions.com.

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