Specialty Pharmacy Prior Authorization (call center/support tech)

Methodist Le Bonheur Healthcare; United States; On-site; USD 36,000 - 48,000; Full time

Job summary

JobRx, Inc. is seeking a Pharmacy Technician responsible for precertification of eligible prescriptions and ensuring documentation meets insurer guidelines for medical necessity and payment.

You will review clinical information, assist with patient assistance programs, and coordinate with insurers to determine proper Prior Authorization and billing codes. The role emphasizes accuracy, communication with providers, and adherence toPMG/insurer protocols.

Qualifications

• High School Diploma or Equivalent.
• Pharmacy Technician Certification (CPhT) required/preferred.
• Tennessee Board of Pharmacy license required.
• PTCB Certification (CPhT) mandatory.
• ExCPT preferred.
• Mississippi Board of Pharmacy license helpful.

Responsibilities

• Precertify eligible prescription medications for inpatient and outpatient services per medical plan documents.
• Review clinical information to evaluate medical necessity and efficiency of prescription use.
• Assist with patient assistance and grant coordination for outpatient pharmacies.
• Analyze information to determine medical necessity and CPT/HCPCS/ICD-10 for Prior Authorization.
• Contact insurers to gather information and organize workflow for procedures.
• Collect and interpret medical documentation for insurer reimbursement and proper charge capture.
• Serve as primary contact with physicians to obtain documentation per insurer guidelines.
• Educate providers on pre-certification protocols and contract guidelines.
• Research denials/trends and propose process improvements.

Skills

EMR documentation

Medical terminology

Attention to detail

Communication

Problem solving

Education

High School Diploma or Equivalent

Pharmacy Technician Certification (CPhT)

Tennessee Pharmacy Technician License

Certified Pharmacy Technician - PTCB

ExCPT (NHA) preferred

Mississippi Pharmacy Technician License

Tools

Microsoft Word

EMR system experience

Job description

Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

A Brief Overview

Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

What you will do

• Responsible for precertification of eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity. Ensures medical documentation is sufficient to meet insurer guidelines for medical necessity documentation and procedure payment.
• Reviews clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of prescription medications.
• Assists with patient assistance and grant coordination for Patients for outpatient pharmacies from designated areas.
• Proactively analyzes information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines. Verifies physician orders are accurate. Determines CPT, HCPCS and ICD-10 codes for proper Prior Authorization.
• Contacts insurance companies and third party administrators to gather information and organize work‑flow based on the requested procedure.
• Collects, reads and interprets medical documentation to determine if the appropriate clinical information has been provided for insurance reimbursement and proper charge capture.
• Serves as primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines. Establishes and maintains rapport with providers as well as ongoing education of providers concerning protocols for pre‑certification.
• Communicates information and acts as a resource to Patient Access, Case Management, and others in regard to contract guidelines and pre‑certification requirements.
• Performs research regarding denials or problematic accounts as necessary. Works to identify trends and root cause of issues and recommend resolutions for future processes.

Education/Formal Training Requirements

• High School Diploma or Equivalent

Work Experience Requirements

• Pharmacy (clinical, hospital, outpatient, or specialty) 3-5 years

Licenses and Certifications Requirements

• Pharmacy Technician - Tennessee - Tennessee Board of Pharmacy
• Certified Pharmacy Technician - Pharmacy Technician Certification Board
• Preferred - Certified Pharmacy Technician- ExCPT - National Healthcareer Association
• Preferred - Pharmacy Technician - Mississippi - Mississippi Board of Pharmacy

Knowledge, Skills and Abilities

• Basic understanding of prescription processing flow. Expertise in utiliizing EMRs to document clinical critieria required for third party approval.
• Knowledgeable of medical terminology, drug nomenclature, symbols and abbreviations associated with pharmacy practice.
• Strong attention to detail and critical thinking skills.
• Ability to speak and communicate effectively with patients, associates, and other health professionals.
• Ability to diagnose a situation and make recommendations on how to resolve problems.
• Experience with a computerized healthcare information system required. Familiarity with fundamental Microsoft Word software.
• Excellent verbal and written communication skills.

Supervision Provided by this Position

• There are no lead or supervisory responsibilities assigned to this position.

Physical Demands

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
• The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
• The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative.