Medication Prior Authorization Specialist - Manning - Quality

Medication Prior Authorization Specialist

Salary: $19.33 - $26.57 Depending on experience

Schedule: Monday - Friday, 8:00am - 4:00pm

Job Purpose

The Medication Prior Authorization Specialist is responsible for facilitating and processing medication prior authorizations to ensure timely patient access to prescribed therapies. This role operates within the Quality Department and is responsible for ensuring that all processes related to medication prior authorizations adhere to regulatory standards, quality control protocols, and best practices. The Medication Prior Authorization Specialist's main function is to complete prescription prior authorizations. The Medication Prior Authorization Specialist ensures patients receive medications that require pre-authorization from insurance carriers. Communicates with plans and pharmacy by analyzing insurance prior authorization requirements. It is the responsibility of the Medication Prior Authorization Specialist to receive, process and document all requirements, submit the required documentation, and update the Prior Authorization submission documents when necessary. They will collaborate with cross-functional teams to monitor, assess, and improve the quality of processes for prescription prior authorizations and medication services. This role requires a deep understanding of quality assurance principles, and strong analytical skills. In addition, the Specialist may be asked to perform other tasks in support of the Quality and Innovation team. The Medication Prior Authorization Specialist serves in a specialized administrative support role.

Essential Job Functions

• Performs and/or completes all assigned duties, tasks, responsibilities, and assignments supporting the quality team with focus on Medication Prior Authorizations within established time frames; meeting established rates of performance for the quality and quantity of work for the position; demonstrating a high level of technical expertise, quality, efficiency, and accuracy in the employee's job performance that ensures the highest standards of excellence.
• Maintains proficient skill levels that meet defined performance expectations for a Medication Prior Authorization Specialist evidenced by successful demonstration of skills performance for this position upon evaluation.
• Always maintains employee and/or patient confidentiality by controlling the environment and information being disclosed to authorized individuals ensuring compliance with all HIPAA and corporate compliance standards, as well as accepted human resources confidentiality standards.
• Understands and complies with all organizational Code of Conduct standards, Policies and Procedures, and Service Excellence requirements with all patients, visitors, employees, and internal/external clients or representatives.
• Always demonstrates a professional attitude and acceptable job performance for all duties, tasks, responsibilities, and assignments for this position at the assigned location and/or duty assignment that supports the operational needs of El Rio Health and as assigned by organizational leadership.
• Possesses and demonstrates the knowledge, understanding, and specialized technical skills to complete all assigned duties, tasks, and responsibilities, in addition to working with the electronic health record.
• Serves as an informational contact point for El Rio's Quality & Innovation Team in relation to Medication Prior Authorizations supporting payors bringing any issues or requests to timely and effective resolution.
• Collects, analyzes, and interprets quality-related data to identify trends and opportunities for enhancement.
• Initiates authorization requests for Pharmacy in accordance with the prior authorization workflow.
• Process faxes within established standards, follow up outbound calls with plans and pharmacies.
• Gains and maintains a comprehensive understanding and proficient ability to ensure full compliance with all regulations, standards, or requirements for all Federal, State, and local laws; as well as all standards and requirements for internal/external grants or funding sources.
• Demonstrates an exceptional level of customer service; answers and responds to all incoming calls, emails, and inquiries in a timely and effective manner, responds to requests and forwards any issues or complaints for resolution.

Minimum Education and Experience

• High School Diploma or General Education Diploma (G.E.D).
• Three (3) years experience working with insurance plans, Pharmacy benefits (PBM), and eligibility.
• Two (2) years experience processing Medication Prior Authorizations, insurance verification and formularies.
• Familiarity with EHR's EPIC

If applicable, equivalent combination of education and experience may be considered, and must be directly related to the functions and responsibilities of the job.

Required Licenses, Certifications, and Registrations

• Current certification in Basic Life Support (BLS) for health care providers.
• Level I fingerprint clearance card: current valid and in good standing or have applied for it within seven working days after beginning employment.
• Employees in this position are required to have reliable transportation that can meet any operational reassignments of the organization during the workday. If an employee is driving during work hours, the employee is required to possess a valid driver's license and must comply with Arizona vehicle insurance requirements.

Preferred Education, Experience, Skills, Abilities

• Associate's Degree in a Business or Finance related field from an accredited College or University.
• A current License as a Pharmacy Technician in accordance with the Arizona State Board of Pharmacy requirements.
• Two (2) years administrative experience, preferably in a healthcare environment.
• Bilingual (English/Spanish) with the ability to speak, read and write in both languages.

Reasonable accommodations may be made to enable individuals with disabilities; known limitations related to pregnancy, childbirth, or related medical conditions; and for sincerely held religious beliefs, observances, and practices to perform the essential functions of the job.

El Rio Health does not discriminate based on race, color, religion, sex (including pregnancy, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, or other non-merit-based factors. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.