Specialty Pharmacy Prior Authorization Specialist

Methodist Le Bonheur Healthcare; Memphis (TN); On-site; USD 38,000 - 52,000; Full time

Job summary

Methodist Le Bonheur Healthcare is seeking a Pharmacy Technician to manage precertification of eligible prescription medications for inpatient and outpatient services. You will verify medical necessity documentation and ensure insurer guidelines are met to support payment for services.

Responsibilities include reviewing clinical information, coordinating with providers, and communicating with insurers to obtain prior authorization and resolve issues, while upholding MLH values and patient care

Qualifications

• High School Diploma or Equivalent is required.
• 3-5 years Pharmacy (clinical, hospital, outpatient, or specialty) experience.
• Tennessee Pharmacy Technician license required; additional certifications preferred.

Responsibilities

• Precertification of eligible prescription medications for inpatient and outpatient services.
• Review clinical information to evaluate necessity and payer approval.
• Assist with patient assistance and grant coordination for outpatient pharmacies.
• Determine proper Prior Authorization and communicate with insurers.
• Collect and interpret medical documentation for reimbursement and charge capture.
• Serve as contact with physicians and providers to gather documentation.

Skills

EMR documentation

Medical terminology

Attention to detail

Verbal & written communication

Problem solving

Microsoft Word

Education

High School Diploma or Equivalent

Tools

EMR software

Microsoft Word

Job description

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. Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.

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

• Required - High School Diploma or Equivalent

Work Experience Requirements

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

Licenses and Certifications Requirements

• Required - Pharmacy Technician - Tennessee - Tennessee Board of Pharmacy
• Required - 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 utilizing EMRs to document clinical criteria 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.