Clinical Authorization and Appeals Specialist

Job Description

Job Description

7,000 Diseases - 500 Treatments - 1 Rare Pharmacy

PANTHERx is the nation’s largest rare disease pharmacy, and we put the patient experience at the top of everything that we do.

If you are looking for a career in the healthcare field that embraces authentic dedication to patient care, you don’t need to look beyond PANTHERx. In every line of service, in every position and area of expertise, PANTHERx associates are driven to provide the highest quality outcomes for our patients.

We are seeking team members who:

Are inspired and compassionate problem solvers;

Produce high quality work;

Thrive in the excitement of the ever-challenging environment of modern medicine; and

Are committed to achieving superior health outcomes for people living with rare and devastating diseases.

At PANTHERx, we know our employees are the driving force in what we do. We cultivate talent and encourage growth within PANTHERx so that our associates can continue to explore their interests and expand their careers. Guided by our mission to provide uncompromising quality every day, we continue our strategic growth to further reach those affected by rare diseases.

Join the PANTHERx team, and define your own RxARE future in healthcare!

Location: Pittsburgh, PA; Hybrid

Classification: Non-Exempt

Status: Full Time

Reports to: Manager, Clinical Programs

Purpose:

The Clinical Authorization and Appeals Specialist provides support and education to health care providers for prescribed treatment therapies. This role serves as a single point of contact for health care providers to coordinate alignment of documentation with prior authorization and appeals criteria. This role submits timely prior authorizations requests, appeals, initiatives to increase patient adherence, and closes collaboration with both internal and external stakeholders.

Responsibilities:

• Educates health care providers regarding prior authorization and appeals criteria for prescribed therapies.
• Assesses clinical documentation provided and assist the health care provider with alignment to specific plan criteria.
• Creates initiatives to increase patient adherence and optimize patient care.
• Possess a broad and deep understanding of assigned disease states, products, and clinical programs.
• Closes collaboration with program team members as well as external stakeholders.
• Performs appropriate and accurate documentation of cases using call management software.
• Demonstrates appropriate judgment skills to be able to make independent clinical decisions.
• Fosters teamwork by trusting and supporting each other while encouraging collaboration at all levels of the organization. Embraces diversity and demonstrates the ability to work together.
• Provides superior customer service to internal and external clients, customers, and patients.
• Assumes accountability for own professional practice in achieving patient outcomes.
• Completes all other duties as assigned.

Required Qualifications:

• Associate degree or bachelor’s degree from an accredited nursing school as a Registered Nurse (RN).
• Must have demonstrated competence in community health or patient care setting, providing direct patient care with patients for 1-3 years.
• Strong writing and grammar skills.
• Strong organizational skills and a thorough knowledge of computers (Microsoft Office and Windows) are required.
• Demonstrated ability to work independently and meet goals.

Preferred Qualifications:

• 1-3 years of specialty pharmacy experience

Work Environment:

PANTHERx Rare Pharmacy offers flexibility only to eligible employees to work hybrid or remotely without compromising work performance, productivity, or team collaboration. This role routinely uses standard office equipment such as computers and phones.

Physical Demands:

While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function of the job.

Benefits:

Hybrid, remote and flexible on-site work schedules are available, based on the position. PANTHERx Rare Pharmacy also affords an excellent benefit package, including but not limited to medical, dental, vision, health savings and flexible spending accounts, 401K with employer matching, employer-paid life insurance and short/long term disability coverage, and an Employee Assistance Program! Generous paid time off is also available to all full-time employees, as well as limited paid time off for part-time employees. Of course we offer paid holidays too!

Equal Opportunity:

PANTHERx Rare Pharmacy is an equal opportunity employer, and does not discriminate in recruiting, hiring, promotions or any term or condition of employment based on race, age, religion, gender, ethnicity, sexual orientation, gender identity, disability, protected veteran's status, or any other characteristic protected by federal, state or local laws.