Mail Order Prior Authorization Specialist

Responsible for

• Precertification of eligible prescriptions
• Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services

Models

Appropriate behavior as exemplified in MLH Mission, Vision and Values

What You Will Do

• Responsible for precertification of eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity
• Ensures medical documentation is sufficient to meet insurer guidelines for medical necessity documentation and procedure payment
• Reviews clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of prescription medications
• Aids in patient assistance and grant coordination for outpatient pharmacies from designated areas
• Proactively analyzes information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines
• Verifies physician orders are accurate
• Determines CPT, HCPCS and ICD-10 codes for proper Prior Authorization
• Contacts insurance companies and third party administrators to gather information and organize work-flow based on the requested procedure
• Collections, reads and interprets medical documentation to determine if the appropriate clinical information has been provided for insurance reimbursement and proper charge capture
• Serves as primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines
• Establishes and maintains rapport with providers as well as ongoing education of providers concerning protocols for pre-certification
• Communicates information and acts as a resource to Patient Access, Case Management, and others in regard to contract guidelines and pre-certification requirements
• Performs research regarding denials or problematic accounts as necessary
• Works to identify trends and root cause of issues and recommend resolutions for future processes

Education & Formal Training Requirements

• Required - High School Diploma or Equivalent
• Required - Pharmacy (clinical, hospital, outpatient, or specialty) 3-5 years
• Required - Pharmacy Technician - Tennessee - Tennessee Board of Pharmacy
• Required - Certified Pharmacy Technician - Pharmacy Technician Certification Board
• Preferred - Certified Pharmacy Technician- ExCPT - National Healthcareer Association
• Preferred - Pharmacy Technician - Mississippi - Mississippi Board of Pharmacy

Knowledge, Skills & Abilities

• Basic understanding of prescription processing flow
• Expertise in utilizing EMRs to document clinical critieria required for third party approval
• Knowledgeable of medical terminology, drug nomenclature, symbols and abbreviations associated with pharmacy practice
• Strong attention to detail and critical thinking skills
• Ability to speak and communicate effectively with patients, associates, and other health professionals
• Ability to diagnose a situation and make recommendations on how to resolve problems
• Experience with a computerized healthcare information system required
• Familiarity with fundamental Microsoft Word software
• Excellent verbal and written communication skills

Supervision Provided

No lead or supervisory responsibilities assigned to this position

Physical Demands

• Light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently
• Close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading
• Not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative