Prior Authorization Coordinator I

About the role

Works as a member of the Prior Authorization Operations team. Processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments. Uses various business applications to perform analysis, obtain information, and enter prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based upon clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.). Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality. Works under general supervision, relying on instructions, work process guidelines, policies & procedures, and company knowledge/experience to perform the functions of the job. Extent of supervision ranges from close, to moderate, to minimal oversight based upon demonstrated skill and performance levels as defined for the position. This position is part of a three level career path with progression opportunities described in the Core Processing Career Path/Succession Planning Guidelines. Essential Duties and Responsibilities include the following. Other duties may be assigned. Process and finalize Prior Authorization (PA) requests within clients' turnaround time and Performance Guarantees utilizing guidelines. Enter PAs into the system and prioritize requests. Check formulary alternatives, review tried and failed medications. Utilize drug references and verify the drug being requested is indicated and approved for the condition. Document all related information regarding the PA approval or non-approval. Respond to requests by faxing status of the PA to the physician or pharmacy Conforms to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making. Partners with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing. Accountable to achieve prior authorization processing productivity and accuracy standards. Analyzes, researches, and resolves prior authorization processing issues as appropriate for experience and career path level, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from team subject matter experts (SME) or supervisor; and referring unique or high dollar requests to supervisor according to guidelines. Coordinates notifications to members, physicians, and pharmacies as required to obtain missing information, manage pended requests, and communicate prior authorization determinations. Documents prior authorization related information and status. Makes outbound calls to obtain information and answer questions about prior authorization status Process and finalize Prior Authorization (PA) requests within clients' turnaround time and Performance Guarantees utilizing guidelines. Enter PAs into the system and prioritize requests. Check formulary alternatives, review tried and failed medications. Utilize drug references and verify the drug being requested is indicated and approved for the condition. Document all related information regarding the PA approval or non-approval. Respond to requests by faxing status of the PA to the physician or pharmacy Conforms to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making. Partners with assigned clin

Benefits

Additional Information

Exemption Status: United States of America (Non-Exempt) $17.69 - $22.55 - $27.41 "Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate." This position is not eligible for Sponsorship. MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution! Job Description

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