Job Description

Job Title:                          Prior Authorization Specialist  

Reports To:                       Associate Pharmacy Director

Job Summary:                  Assist Chiricahua Community Health Centers in prior authorization processing, approvals, and denials. The ideal candidate will obtain prior authorizations from insurance companies on behalf of the clinic and the patient.

                                                                                                                                                                                                         

Qualifications and Requirements:

To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  This job description in no way implies that these are the only duties to be performed and may be modified, interpreted and/or applied in any way, as necessary. Maintaining regular and punctual attendance is required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

 

Essential Job Duties:

  • Demonstrates the ability to request, prepare, and recognize the documentation required to support the medical necessity for the service being authorized.
  • Responds to all medications that meet authorization requirements by monitoring databases, systems, and taskings.
  • Prioritizes authorization requests according to urgency.
  • Coordinates with patients, clinic staff, and insurance companies to obtain authorization.
  • Utilizes phone, fax, or website to initiate and obtain authorization for prescription medications.
  • Maintains appropriate logs or reports and communicates the need for appeals based on    denied authorizations.
  • Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer
  • Provides adequate documentation in patients’ charts of authorization, approval, and/or denial, including, but not limited to, authorization numbers, insurance representative’s name, and dates of approval.
  • Maintains patient
  • Meets or exceeds productivity standards in the completion of daily assignments and accurate
  • Assists in maintaining claim billing process and procedure
  • Additional job duties may be required to meet the needs of the
  • Receives and processes prior authorizations and clinic prior authorization requests promptly and accurately.
  • Answer’s phone calls, responds to caller questions as able or/or transfer/directs caller to appropriate phone number.
  • Maintains and files logs, records, and other required documentation accurately.
  • Ensures operation of provided equipment by completing preventive maintenance and cleaning requirements, following manufacture’s instructions, reporting malfunctions, and requesting repairs.
  • Participates in staff and other meetings as required.
  • Provides orientation and training to new team members and assists co-workers in completion of tasks.

 

Required Education, Experience, Certificates & Licenses:

  • High school or G.E.D.
  • PTCB Certification preferred.
  • Current AZ Board of Pharmacy Technician License preferred.
  • One year of experience as a Pharmacy Technician processing prescription claims or in a similar setting preferred.
  • Driver’s License and proof of insurance may be required if requesting mileage reimbursement.
  • Any combination of education and/or experience that provides the necessary skills and sensitivity.
  • Valid Fingerprint Clearance card.

 

Required Language Skills:

  • Ability to comprehend and compose instructions, correspondence, and communications in English in both oral and written format.
  • Bilingual in English and Spanish preferred, but not required.
  • Ability to effectively present information in one-on-one and small group situations to patients, internal providers and staff and other agency staff working in cooperation with the organization.

 

Physical Requirements:

  • Ability to occasionally exert enough force to move objects weighing up to 25 pounds.
  • Ability to continuously remain in a stationary position.
  • Ability to stand for extended periods.
  • Ability to constantly move about inside the workplace to assist patients, operate office equipment, etc.
  • Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone and other office machinery, and grasp and seize small objects such as medication tablets and containers.
  • Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents, as well as accurately identify and distinguish colors.
  • Ability to perceive the size, shape, temperature and/or texture of objects by touch.
  • Ability to discern the nature of sounds at a normal spoken volume.

 

Other Required Knowledge, Skills, and Abilities:

  • Ability to perform medical math that may include the use of ratio/proportion, dosage calculation, metric and household equivalents, roman numerals, abbreviations, and general math including percentages, etc.
  • Ability to skillfully gather and analyze data.
  • Ability to perform a variety of assignments and make decisions requiring considerable independent judgment.
  • Displays high level of critical thinking and problem-solving skills.
  • Displays sound and accurate judgment and ability to make timely decisions.
  • Knowledge of health plans and community health centers preferred.
  • Knowledge of HIPAA and Corporate Compliance rules and regulations.
  • Knowledge of 340B regulations.
  • Computer literacy required with proficiency in use of all Microsoft Office programs.
  • Ability to prioritize and plan work activities, use time efficiently and develop realistic action plans.
  • Ability to provide excellent customer service by mail, telephone, and in person.

 

Work Environment & Conditions:

  • Work environment is typical of a health care facility setting with occasional exposure to communicable diseases, bodily fluids, and hazardous chemicals.
  • Work requires reliable transportation as position requires occasional travel and extended hours to include early mornings, evenings, and weekends.