Pharmacy Prior Authorization Agent-Specialty

Major Responsibilities

Complete insurance verification and eligibility checks.
Collect and accurately document initial pre-certification/authorization information if available. Initiates the process of obtaining a required referral/authorization if not obtained.
Work assigned Epic work queue, following the department’s workflow process on appropriately transferring, deferring, or removing orders from the work queue.
Proactively communicate issues involving customer service and process improvement opportunities to management.
Maintains excellent public relations with patients, patients’ families and clinical staff as well as demonstrates a willingness and ability to work collaboratively with others for concise and timely flow of information.
Maintains knowledge of and reference materials for Medicare, Medicaid and third-party payer requirements guidelines and policies, insurance plans requiring pre-authorization/referral and a list of current accepted insurance plans.
Update the patient, physician's office, and any necessary parties, through multiple methods as appropriate (including telephone, in-basket messaging, and electronic medical record), regarding responses and outcomes of the prior authorizations.
Act as a liaison between physician's office, patient, and pharmacy benefit manager to initiate and resolve appeals, as needed.
May identify and assist patients with access to internal and external financial assistance programs.
May communicate to the patient and/or physician's office when authorization is not obtained, or services are not covered, and explains the potential financial responsibility. Coordinates with patient, clinical team, and assistance programs to secure reimbursement or alternative covered options.
Manages incoming and outgoing calls, which may include other Advocate team members, departments, patients, insurance plans and/or copay foundation/assistance programs.

Licensure, Registration, And/or Certification Required

None Required

Education Required

High School Graduate

Experience Required

Typically requires 1 year of experience in health care, insurance industry, pharmacy, or medical background

Knowledge, Skills & Abilities Required

Demonstrate ability to identify and understand issues and problems. Examines data and draws logical conclusions based on information available
Ability to problem solve in a high profile and high stress area
Mathematical aptitude, effective communication, and critical thinking skills
Ability to prioritize and organize workload
Excellent Verbal and written communication skills
Demonstrated technical proficiency including experience with insurance authorization/eligibility tools, EPIC, Microsoft Office, Internet browser and telephony systems

Physical Requirements And Working Conditions

Operates all equipment necessary to perform the job
Exposed to normal office environment areas, or remote work area
Must have the ability to lift to 10 lbs. occasionally
Uses a computer continuously throughout the workday
Must be able to sit for extended periods of time

Preferred Job Requirements

Preferred Education

No additional education is required

Preferred Experience

No additional experience necessary

Preferred Knowledge/Skills/Abilities

Knowledge of medical terminology

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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