Prior Authorization Specialist

Job Description

Join TriHealth at Montgomery Fitness Pavilion as a Prior Authorization Specialist , where you'll play a vital role in helping patients access the care and services they need. In this position, you'll collaborate closely with providers, clinical teams, patients, and insurance companies to ensure authorizations are obtained accurately and efficiently, helping create a seamless patient experience. Montgomery Fitness Pavilion offers a welcoming, team-oriented environment focused on wellness, preventive care, and exceptional service. If you're detail-oriented, enjoy problem-solving, and thrive in a fast-paced healthcare setting where your work directly supports both patients and caregivers, this is an opportunity to make a meaningful impact while growing your career with a respected healthcare organization.

Location: Montgomery Fitness Pavillion

Schedule: Full time day shift

Incentives & Benefits:

We offer competitive shift differentials, opportunities for professional growth, and a comprehensive benefits package that may include medical, dental, vision, paid time off, retirement savings plans, and tuition reimbursement.

*PRN positions not eligible for TriHealth benefits

Minimum Job Requirements:

• High School Degree or Medical Assistant
• Certified Pharmacy Technician or Certified Medical Assistant desired
• Prior experience with medication Epic and/or prior authorizations desirable
• 2-3 years experience Clinical Pharmacy Pharmacy Technician or Medical Assistant
  Job Overview:

The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical information from electronic medical record, and timely communication with patients, prescribers and physician office staff. Candidates should possess knowledge of third party reimbursement regulations and medical terminology as well as seek out assistance from a pharmacist or physician as necessary. Success in this role will require strong communication, interpersonal, and problem solving skills. This person should be able to interact and communicate effectively with internal and external customers, physician office staff, and all members of the organization.

Job Responsibilities:

• Demonstrates the ability to prioritize daily tasks and has a working knowledge of department's day-to-day operations and initiatives. Is an active participant in meetings, work groups, and committees. Participates in departmental and organizational feedback opportunities. Assists in the training of new employees. Meets or exceeds department's internal quality performance metrics. Participates in quality improvement activities and projects to monitor the effectiveness of department's services.
• Meets or exceeds department's customer satisfaction targets and goals. Assumes responsibility for achieving department satisfaction goals and demonstrates a commitment to service excellence for internal and external customers. Proactively communicates with patients and physician office staff. Serves as a subject matter expert for the prior authorization process as a whole. Meets or exceeds department's goals for formulary adherence measures, and other cost control initiatives identified as a priority for the department. Works collaboratively with pharmacists, prescribers, physician office staff and all members of the health care team to coordinate all aspects of the prior authorization process and documents activities appropriately in the electronic medical record.

Working Conditions:

Climbing - Rarely

Concentrating - Frequently

Continous Learning - Consistently

Hearing: Conversation - Consistently

Interpersonal Communication - Consistently

Kneeling - Rarely

Lifting <10 Lbs - Occasionally

Lifting 50+ Lbs - Rarely

Lifting 11-50 Lbs - Rarely

Pulling - Rarely

Pushing - Rarely

Reaching - Rarely

Reading - Consistently

Sitting - Consistently

Standing - Occasionally

Stooping - Rarely

Thinking/Reasoning - Consistently

Use of Hands - Consistently

Color Vision - Consistently

Walking - Rarely

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:

Serve: ALWAYS...

• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"

• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist

• Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS...

• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met

• Offer patients and guests priority when waiting (lines, elevators)

• Work on improving quality, safety, and service

Respect: ALWAYS...

• Respect cultural and spiritual differences and honor individual preferences.

• Respect everyone's opinion and contribution, regardless of title/role.

• Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS...

• Value the time of others by striving to be on time, prepared and actively participating.

• Pick up trash, ensuring the physical environment is clean and safe.

• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS...

• Acknowledge wins and frequently thank team members and others for contributions.

• Show courtesy and compassion with customers, team members and the community