Prior Authorization Coordinator I

Exemption Status: Non-Exempt (United States of America)

Pay range: $16.72 – $20.90 – $25.08. Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.

About the role

Works as a member of the Prior Authorization Operations team. Processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments. Uses various business applications to perform analysis, obtain information, and enter prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based upon clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.). Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality. Works under general supervision, relying on instructions, work process guidelines, policies & procedures, and company knowledge/experience to perform the functions of the job.

This position is part of a three-level career path with progression opportunities described in the Core Processing Career Path/Succession Planning Guidelines.

Responsibilities

• Process and finalize Prior Authorization (PA) requests within clients’ turnaround time and Performance Guarantees utilizing guidelines.
• Enter PAs into the system and prioritize requests.
• Check formulary alternatives, review tried and failed medications.
• Utilize drug references and verify the drug being requested is indicated and approved for the condition.
• Document all related information regarding the PA approval or non-approval.
• Respond to requests by faxing status of the PA to the physician or pharmacy.
• Conform to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making.
• Partner with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing.
• Achieve prior authorization processing productivity and accuracy standards.
• Analyze, research, and resolve prior authorization processing issues as appropriate for experience and career path level, including:
  • Making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies.
  • Obtaining input from team subject matter experts (SME) or supervisor.
  • Referring unique or high dollar requests to supervisor according to guidelines.
• Coordinate notifications to members, physicians, and pharmacies as required to obtain missing information, manage pended requests, and communicate prior authorization determinations.
• Document prior authorization related information and status.
• Make outbound calls to obtain information and answer questions about prior authorization status.
• Collaborate with MCO and Self-Insured client teams to understand PBM clients’ prior authorization processing requirements and expectations.
• Partner with client teams to complete special prior authorization processing projects and provide accurate, timely, and reliable information to client claim inquiries (PAC II/II).
• Collaborate with Contact Center Services in resolving prior authorization inquiries.
• Handle Provider, Pharmacy, and member calls to complete prior authorization and Peer to Peer requests based on client-specific requirements.
• Protect and maintain confidentiality and privacy of all prior authorization and member information, including following strict protocols for date stamping and storage/security of prior authorization forms and related information.

Requirements

• GED/HS Diploma and 1+ year experience or equivalent combination of education and experience.
• Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs.
• Experience with Windows-based database programs.
• Must successfully complete one of the national certification exams OR obtain state licensure (in any U.S. State).
• Maintain a current Pharmacy Technician License and/or CPhT certification without restriction.

Skills

• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
• Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
• Ability to read and comprehend simple instructions, short correspondence, and memos.
• Ability to write simple correspondence.
• Composure, decision quality, organizational agility, problem solving, customer focus, drive for results, peer relations, time management, dealing with ambiguity, learning on the fly, and political savvy.

Work Environment

• This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements).
• Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.
• This is a full-time non-exempt position requiring the ability to work overtime from time to time, including nights, weekends, or holidays as required.
• Typical working hours are Monday through Friday from 8:00 am to 5:00 pm.
• No travel required, but attendance may be required at various local conferences and meetings.
• While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel; and reach with hands and arms. The employee must occasionally lift and/or move up to 10 pounds.
• The noise level in the work environment is usually moderate (e.g., business office with computers and printers, light traffic).

Benefits

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus