Prior Authorization Representative

About the role

This position will work closely with the Benefits Verification Team to validate patient's insurance plans, prescriptions, and eligibility. Job responsibilities include ability to read prescriptions, convert prescriptions into authorizations, and interpret medical policies. Prior Authorization Representatives are responsible for contacting physician’s offices to validate prescriptions, obtain clinical documentation, and initiate prior authorizations through insurance plans.

Essential Duties

• Contact plans (PBM or Major Medical) to validate requests sent from BV
• Contact physician offices to obtain current prescriptions and required clinical documentation
• Validate that received clinical documentation meets plan requirements
• Initiate prior authorizations through CoverMyMeds and follow up on all pending PAs within 48 hours
• Respond to urgent requests from the Patient Care Coordinator Team or Program Manager in a timely manner
• Obtain approval and denial letters
• Submit new and re-authorizations through the Complex audit process
• Initiate re-authorizations 30 days prior to expiration
• Able to meet daily key performance indicators (KPIs) in a fast-paced environment
• Strong attention to detail with a willingness to go the extra mile
• Able to multitask and manage priorities effectively
• Flexibility to work overtime as needed
• Other duties as assigned

Knowledge, Skills, and Training

• Experience with Major Medical Insurance
• Knowledge of Pharmacy Benefit
• Knowledge of HCPC Codes (J-Codes)
• Knowledge of ICD-10 Codes (Diagnoses Codes)
• Familiar with medical documentation such as H&P’s, Genetic testing, etc.
• Ability to read prescriptions
• Ability to convert a prescription into an authorization request based on payer requirements
• Ability to interpret medical policies
• Proficiency in Microsoft Office (including Excel/TEAMS)
• Strong data entry and quality assurance skills with attention to detail
• Ability to multitask in a fast-paced environment
• Self-starter with strong organizational skills

Benefits

• Medical Coverage, Dental, and Vision Coverage
• 401(k) with employer match
• Accident and Critical Illness coverage
• Company-paid life insurance options
• Generous PTO, paid holidays, and floating holidays
• Tuition reimbursement program

Disclaimer

The information written in this job description indicates the general nature and level of work to be performed. This job description is not designed to contain or be interpreted as totally comprehensive of every job duty, responsibility, or qualification required by an employee assigned to this job. While employed in this position, an employee may be required to perform other assignments not listed in this job description.

Equal Employment Opportunity

Orsini Rare Disease Pharmacy Solutions is committed to the principle of Equal Employment Opportunity for all employees and applicants. It is our policy to ensure that both current and prospective employees are afforded equal employment opportunity without consideration of race, religious creed, color, national origin, nationality, ancestry, age, sex, marital status, sexual orientation, or present or past disability (unless the nature and extent of the disability precludes performance of the essential functions of the job with or without a reasonable accommodation) in accordance with local, state and federal laws.

Americans with Disabilities Act

Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

E-Verify Participation Notice

We participate in the federal E-Verify program to confirm the identity and employment eligibility of all newly hired employees.