We are seeking a dedicated Prior Authorization Specialist to join our team. In this role, you will facilitate the processing and communication of specialty medication prior authorization (PA) requests within our Specialty Medical Prior Authorization department. Reporting directly to the Pharmacy Operations Manager, you will collaborate closely with physician office staff, customer service, admissions, and pharmacy operations departments to ensure efficient communication of prior authorization statuses. Your responsibilities will also include overseeing fax processing and providing essential telephone support to prescriber office staff, pharmacies, and members, adhering to program criteria.
Responsibilities
Review and process prior authorizations based on established criteria and procedures.
Provide after-hours nurse availability for urgent PA requests on a rotational basis.
Offer internal nurse support to both the PA team and member services department.
Escalate cases that do not meet clinical criteria to the appropriate Pharmacist and MD teams.
Manage priorities effectively, demonstrating urgency in all calls and assignments.
Demonstrate excellent verbal and written communication skills.
Collaborate with pharmacists, clinical colleagues, healthcare professionals, and members.
Ensure compliance with all prior authorization procedures to maintain accuracy.
Train and mentor team members on prior authorization processes.
Complete additional PA-related tasks as assigned by PA leadership.
Requirements
Minimum of 1 year experience in reviewing and processing prior authorizations against health plan criteria in a clinical setting (e.g., medical office or Pharmacy Benefits Manager).
3 to 5 years of prior related work experience as an LPN/LVN in a medical office, PBM, or clinical setting.
Proficiency in MS Office and other Windows-based computer applications, along with strong phone etiquette.
Work From Home Requirements
Dedicated workspace during working hours that ensures confidentiality and privacy.
High-speed internet with a minimum speed of 25 Mbps download and 3 Mbps upload.
Access to a smartphone for VPN token usage.
Additional Information
Compensation: $27.00 to $28.08 per hour.
Benefits: Medical, dental, vision, life insurance, short-term disability, voluntary benefits, EAP program, commuter benefits, and 401K plan.
Paid Leave: Includes Paid Sick Leave and other applicable leave as per Federal, State, or local law, plus Holiday pay eligibility.
Employment Type: Full-Time
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Human Resources Services
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