Prior Authorization Specialist

Job Description

Job Description

Title:  Prior Authorization Specialist 
Reports to:  Director, Pharmacy Operations 
Classification:  Individual Contributor 
Location:  MA (Remote)
Job description revision number and date:  V 3.0; 09.9.2024

Community Care Cooperative (C3) is a 501(c)(3) non-profit multi-service organization governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We fulfill two primary business functions for the FQHCs we work with. First, we are an FQHC-led accountable care organization (ACO); second, we are a Management Services Organization (MSO) for FQHCs.

As an ACO, we negotiate value-based payor contracts on behalf of our FQHCs, hold and operate those contracts (including fulfilling many compliance, financial management, and population health management functions), and maximize the return to FQHCs of any incentive dollars earned. We are proud to be the market leader in the MassHealth ACO Program. We are the largest Medicaid ACO in Massachusetts, and we operate a variety of business offerings nationwide.

As an MSO, we (along with our subsidiary companies, which are also FQHC-led non-profits) provide several financial, operational, and technological services to groups of FQHCs. These services include Epic EHR licensing and implementation; pharmacy operations consulting as well as the building and direct operation of on-site retail pharmacies; billing and credentialing; employer-sponsored insurance; and others.

We are a fast-growing, dynamic organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

This position will be housed under a subsidiary organization of C3, Community Pharmacy Cooperative, LLC (CPC). The Prior Authorization Specialist is responsible for processing and submitting prior authorizations on behalf of FQHCs working with C3/CPC. Meeting the pharmacy related needs of the ACO and its members is the focus of CPC. The Prior Authorization Specialist’s duties include ensuring that prior authorizations are submitted in an accurate and efficient manner, communicating with providers, patients, and health center pharmacy teams to optimize patient care.

• This position will support the management of patients requiring prior authorizations
• Providing prior authorization services, including insurance benefit investigation, copay assistance, foundation support, and insourcing the dispensing function of Specialty Medications
• Identification and qualification of patients eligible for medication patient assistance programs and foundations
• Communicates with providers, patients, pharmacy and health center teams in a professional and efficient manner
• Interfaces with program administrators for reimbursement assistance programs sponsored by the drug manufacturer
• Tracks, documents, and reports out cost savings associated with patient assistance drug recovery programs and provides updates to pharmacy management
• Provides guidance to patients on patient assistance programs (e.g. provide manufacturer coupons to patients, if available)
• Follow all applicable departmental and CPC Policies and Procedures (as they pertain to operations, quality assurance, goals and priorities)
• Customer Service- communicate with patients in a friendly, welcoming manner with greeting provided by management
• Completion of updating accurate demographic information such as address, date of birth, insurance information and allergies
• Resolve insurance related issues, including prior authorizations, and assist patients with various forms of financial assistance

• Light work: Exerting up to 20 pounds of force frequently to move objects
• Must be able to remain in a stationary position 50-75% of the time

• Expertise in prior authorization submission to PBMs
• Ability to manage processes and develop implementation strategies
• Previous experience in a pharmacy, retail, medical, or customer service setting
• Familiarity with Microsoft Word and Excel
• Strong analytical and organizational skills including ability to analyze data to identify trends and communicate them through effective reporting methods
• Strong attention to detail
• Excellent oral, written, and verbal communication skills including experience presenting complex information to senior leaders
• Skilled in exercising a high degree of initiative, judgement, discretion, and decision making to achieve objectives

• Familiarity with the MassHealth ACO program
• Familiarity with Federally Qualified Health Centers
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred

• Current licensure in Commonwealth of Massachusetts as a pharmacy technician
• 1 year experience in submitting prior authorizations on behalf of a medical center
• GED or High School diploma required

** In compliance with Infection Control practices per Mass.gov recommendations, we

require all employees to be vaccinated consistent with applicable law. **