Prior Authorization Specialist

Job Description:
The Rep I, Clinical Services takes in-bound calls from providers, pharmacies, members, etc providing professional and courteous phone assistance to all callers through the criteria based prior authorization process. Maintains complete, timely and accurate documentation of reviews. Transfers all clinical questions, escalations and judgement calls to the pharmacist team.
The Rep I, Clinical Services will also assist with other duties as needed to include but not limited to outbound calls, reviewing and processing Prior Auth's received via fax and ePA, monitoring and responding to inquiries via department mailboxes and other duties as assigned by the leadership team.
Work closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business and in accordance with Medicare Part D CMS Regulations. Must apply information provided through multiple channels to the plan criteria defined through work instruction. Research and conduct outreach via phone to requesting providers to obtain additional information to process coverage requests and complete all necessary actions to close cases. Responsible for research and correction of any issues found in the overall process. Phone assistance is required to initiate and/or resolve coverage requests. Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed. Must maintain compliance at all times with CMS and department standards. Position requires schedule flexibility and additional cross training to learn all lines of business. Flexibility for movement to different parts of the business to support volume where needed.


Responsibilities:

• Utilizing multiple software systems to complete Medicare appeals case reviews
• Meeting or exceeding government mandated timelines
• Complying with turnaround time, productivity and quality standards
• Conveying resolution to beneficiary or provider via direct communication and professional correspondence
• Acquiring and maintaining basic knowledge of relevant and changing Med D guidance
• Effectively manage work volume by handling inbound calls/fax/ePA requests utilizing appropriate courteous and professional behaviour based upon established standards.
• Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.
• Communication with other internal groups regarding determination status and results (seniors, pharmacists, appeals, etc).
• Identify and elevate clinical inquiries to the pharmacist team as appropriate.

Experience:

• 0-3 years in a customer service or call centre environment managing 75 calls/day.
• Six months of PBM/pharmaceutical related work strongly desired
• At least two years of general business experience that includes problem resolution, business writing, quality improvement and customer service

Skills:

• Prior Authorization
• Medicare and Medicaid
• Call handling experience.

Education:
High School diploma or GED


About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit


US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.