Specialist I, Prior Authorization

Lumicera; Northern (KY); Hybrid; USD 28,000 - 32,000; Full time

Job summary

Lumicera Health Services, a Navitus-powered specialty pharmacy solutions provider, seeks a Specialist I, Prior Authorization. You will review, process, and troubleshoot incoming Prior Authorization requests via phone, fax, and web, ensuring compliance and timely handling.

You will collaborate with clinical teams to meet performance metrics, maintain privacy per HIPAA, and develop knowledge of Medicare/Medicaid programs.

Qualifications

• High school diploma or equivalent required.
• Post high school education such as LPN, CPhT preferred.
• Experience in health insurance/pharmacy insurance or managed care preferred.
• Prior authorization processing experience desired.
• Experience in PBM or managed care call center desired.
• Experience in mail or retail pharmacy setting desired.
• Experience with Medicare/Medicaid regulatory guidance desired.
• Compliance program participation and cooperative work style expected.

Responsibilities

• Research and analyze electronic and manual claims; troubleshoot issues.
• Communicate prior authorization criteria to providers.
• Assist providers in submitting prior authorization requests with formulary information.
• Develop and maintain knowledge of Medicare D, Medicaid, and/or Exchange programs.
• Participate in Prior Authorization projects or other Navitus department projects.
• Protect patient health information and comply with HIPAA.
• Use downtime for eLearning and professional development; participate in Navitus CPhT program.
• Maintain hours and provide coverage as needed.
• Other duties as assigned.

Skills

Customer service

Data entry

Communication

Problem solving

Education

High school diploma or equivalent

L.P.N. (preferred)

Certified Pharmacy Technician (CPhT)

Medical Terminology

Medical Transcriptionist

Job description

Company

Lumicera

About Us

Lumicera - Lumicera Health Services Powered by Navitus - Innovative Specialty Pharmacy Solutions- Lumicera Health Services is defining the “new norm” in specialty pharmacy to optimize patient well-being through our core principles of transparency and stewardship. Here at Lumicera, our team members work in an environment that celebrates creativity and fosters diversity. Current associates must use SSO login option at https://employees-navitus.icims.com/ to be considered for internal opportunities. We are committed to providing equal employment opportunity to all applicants and employees and comply with all applicable nondiscrimination regulations, including those related to protected veterans and individuals with disabilities. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or handicap.

Pay Range

USD $20.00 - USD $22.50 /Hr.

STAR Bonus % (At Risk Maximum)

0.00 - Ineligible

Work Schedule Description (e.g. M-F 8am to 5pm)

M-F 8am to 5pm

Overview

The Specialist I, Prior Authorization (PAS) will review, process, and troubleshoot incoming Prior Authorization requests for various medications. The Specialist I, Prior Authorization (PAS) will accurately process the requests according to regulatory and client specific guidelines. The PAS will work with other team members to meet the departmental performance metrics and maintain compliance. The PAS will work with clinical to ensure requests are processed accurately and timely. The PAS will process requests that come in via phone, fax, and web submission.

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team?

• Research and analyze electronic and manual claims. Apply troubleshooting skills to resolve issues as allowed by the individual benefit
• Communicate prior authorization criteria to providers
• Act as a provider help desk specialist to aid providers in submitting prior authorization requests, providing formulary product information, and communicating prior authorization request status
• Develop and maintain knowledge of Medicare D, Medicaid, and/or Exchange programs
• Participate in ad hoc or regularly scheduled Prior Authorization projects or projects for other Navitus departments
• Protect all personal health information and abide by all HIPAA regulations and confidentiality requirements
• Utilize work down time for personal and professional development through such activities eLearning classes, participation in the Navitus CPhT program, and by continually reviewing all available resources used in prior authorization processing
• Maintain scheduled hours and demonstrate flexibility to aid in hour coverage
• Other duties as assigned

Qualifications

What our team expects from you?

• A high school degree or equivalent. Post high school education desired such as L.P.N., Certified Pharmacy Technician, Medical Terminology, or Medical Transcriptionist
• Previous customer service experience required
• Previous data entry experience preferred
• Experience in health insurance/pharmacy insurance or managed care organization preferred
• Prior authorization processing experience desired
• Experience in a PBM or managed care call center desired
• Experience in a mail or retail pharmacy setting desired
• Experience with Medicare and/or Medicaid regulatory guidance desired
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

Location : Address

Remote

Location : Country

US