REMOTE Prior Authorization Representative
: Job Details :

Description:The Pharmacy Prior Authorization Technician performs functions as permitted by law including the initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed utilizing pharmacy management drug policies and procedures. This position accurately prepares and interprets cases for UM (utilization management) reviews and determination. In addition, the Technician is the content expert for the applications used to process these requests. The Technician acts as a resource for staff regarding members' specific contract benefits, consistent with products, policies and procedures and related health plan functions such as member services, claims, and the referral/authorization process. This position provides leadership and expertise in the intake area of the prior authorization process for medications processed either through the pharmacy or medical benefit and in processing exception/prior authorization requests that follow standard protocols.Skills:Prior authorizationInsurance verificationHealth careInsuranceData entryMedical terminologyCall centerCustomer serviceInsurance eligibilityCoordination of benefitsEMRPay: $18-$20/hrShift: M-F 8am-5pm EST (no part time hours being offered)Remote but you must live in one of their operating areas:Niagara CountyGenesee CountyWyoming CountyAllegany CountyCattaraugus CountyChautauqua CountyAdditional Skills & Qualifications:Conducts an initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member's benefit.Routes cases directly to the pharmacist/medical director for final determination, as directed.Issues verbal and written member notification as required.Reviews and interprets prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of prior authorization review is required, documents any relevant medication history and missing information to assist the pharmacist/nurse/physician in the review process.Develops and implements process improvement to increase efficiency in the review process for the clinical staff.Works with requesting providers, clinical pharmacists, and other internal staff, as appropriate, in determining whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy and specific coverage criteria.Can point out nuances that may not be readily apparent regarding the request.Contacts pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed through the point-of-sale system and/or medical claim system in order to optimize the member experience.Acts as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy and/or medical claims with prior authorization information on file or needed for the member.Responsible for assuring appropriate auth entry across all lines of business. Ensure care management system interfaces to claim processing system for claim payment. Manual manipulation of auth may be required upon case completion.Performs system testing as required for upgrades and enhancements to the care management system.Acts as a content expert for prior authorization intake for our customers, both internal and external. ServesExperience :+ Communication skills are a MUST+ Prior Authorization experience is highly preferred!+ Pharmacy Technician experience is a MUST!+ Must have CPhT+ Healthcare knowledge, medical secretary, pharmacy and outreach experience highly preferred not required.+ High School Diploma required, Associate degree and higher education is preferred .Experience Level:Expert LevelAbout TEKsystems:We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.