Specialty Pharmacy Prior Authorization Specialist

Methodist Le Bonheur Healthcare; Memphis (TN); On-site; USD 25,000 - 36,000; Full time

Job summary

Methodist Le Bonheur Healthcare in Memphis, TN seeks a Pharmacy Technician focused on precertification for inpatient and outpatient prescriptions. You will verify medical necessity, ensure complete documentation, and collaborate with physicians and insurer representatives to secure approvals.

The role requires strong knowledge of medical terminology, EMR usage, and accurate coding for prior authorizations. Excellent communication skills and attention to detail are essential, with opportunities

Qualifications

• Pharmacy technician with clinic, hospital, outpatient, or specialty experience.
• Knowledge of medical terminology and drug nomenclature essential.
• Ability to document criteria for third party approval using EMRs.

Responsibilities

• Precertify eligible prescription medications for inpatient and outpatient services according to medical plan documents.
• Ensure documentation meets insurer guidelines for medical necessity and payment.
• Review clinical information to evaluate necessity and efficiency of prescribed medications.
• Assist patient assistance and grant coordination for outpatient pharmacies.
• Contact insurers to gather information and organize workflow for procedures.
• Verify physician orders, determine CPT/HCPCS/ICD-10 codes for prior authorization.
• Serve as liaison with physicians and offices to collect documentation per guidelines.
• Identify trends and root causes to improve future processes.

Skills

Communication skills

Attention to detail

Critical thinking

Problem solving

Team collaboration

Education

High School Diploma or Equivalent

Registered Pharmacy Technician - Tennessee Board of Pharmacy

Certified Pharmacy Technician - PTCB

ExCPT Certification - NHA

Pharmacy Technician Certification - Mississippi Board (Preferred)

Tools

EMR systems

Microsoft Word

Job description

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One! We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid‑South. 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.

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

• 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 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.

Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity.

Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community. Within any role at Methodist Le Bonheur, you can play a rewarding and fulfilling part in helping us provide high-quality, innovative and compassionate care to the people of Memphis and the Mid‑South.

Our goal is to improve every life we touch, including our Associates. For over a century, we’ve served the health care needs of the people of Memphis and the Mid‑South, and we value the dedicated individuals who play such a crucial role in helping us fulfill our mission.

With Methodist Le Bonheur, you’ll be recognized and rewarded, treated with respect and given many opportunities to learn, grow and build a fulfilling career.

Because we’re not at our best until you are at yours.