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About the Role

The Prior Authorization Coordinator will facilitate the logging and tracking of prior authorization, appeal, reimbursement, and grievance requests, ensuring timely resolution and adherence to regulatory requirements. This role also involves managing the pharmacy medical exception line to address provider questions about formularies and providing administrative support for prior authorization processes.

Responsibilities

Facilitate the logging in and out of all prior authorization, appeal, reimbursement and grievance requests.
Follow up on requests to ensure all are resolved and completed in a timely manner.
Ensure all steps involved with the process are completed and all regulatory requirements are met or exceeded.
Responsible for the pharmacy medical exception line to address provider questions regarding the formularies for all lines of business serviced by Pharmacy Benefit Dimensions.
Provide high quality, diverse administrative support including faxing prior authorization requests, completing decision letters by faxing and copying, making decision notification phone calls to members and physicians, filing, and document scanning preparation.
Assist Clinical Review Pharmacist in making appropriate decisions by verifying member and provider eligibility and filing requests into the correct member folder.
Enter data and ensure complete accuracy on all statistics by logging prior authorization requests into pharmacy systems.
Complete requests by entering overrides into the appropriate pharmacy system and updating all information in required documentation systems.
Transcribe Medical Director decisions into systems.
Complete various reports, reimbursement requests, IRO and review of vendor emails/reports as assigned by the Supervisor.
Facilitate follow-up phone calls to members and providers for clinical approvals and denials.
Initiate outbound telephone calls to members/physicians regarding decisions within all regulatory time frame requirements.
Answer and provide resolution to provider and internal callers regarding formulary/prior authorization questions for all lines of business.
Log all calls into call documentation systems.
Research and respond to escalated and complex inquiries regarding Pharmacy questions or concerns.
Ensure that all callers obtain accurate and up-to-date information on policies and procedures and communicate a successful resolution to inquiries.
Provide callbacks when necessary.
Provide support for all required letters within the required timeframes.
Fax prior authorization requests including requests for additional information and completed requests.
Copy and mail completed requests and related documents.
Prepare completed requests for scanning into documentation systems.
Maintain proper storage of all files, in accordance with the corporate retention policy.
Occasional holidays, weekends and overtime will be a requirement of the position.

Requirements

High school diploma or GED required.
Two (2) years of experience in pharmacy or health insurance operations required OR one (1) year of experience as a temporary associate in the Prior Authorization Coordinator role or Prior Authorization department required.
Written and verbal communication skills.
Excellent organizational and time management skills.
Excellent ability to absorb new concepts and adapt to a changing environment.
Exhibit creativity and self-motivation, with the ability to effectively solve problems as they arise.
Demonstration of math aptitude for purposes of calculating simple drug requirements when given dose and price calculations.
Proven examples of displaying the PBD values: Trusted Advisor, Innovative, Excellence, Guardianship, Dedication and Caring.

Skills

Pharmacy experience strongly preferred.
General knowledge of drug names, therapeutic categories, dosage forms, manufacturers and packaging preferred.
Familiarity with HMO concept.
Experience with pharmacy on-line system preferred.

Location

Williamsville

Work Type

Hybrid

Experience Level

2 years of experience in pharmacy or health insurance operations
1 year of experience as a temporary associate in the Prior Authorization Coordinator role or Prior Authorization department

Education Level

High school diploma or GED
Associates degree preferred

Salary/Compensations

$22.00 hourly

Benefits

Scorecard incentive
Full range of benefits
Generous paid time off

About the Company

We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.

Equal Opportunity

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.
Click here for additional EEO/AAP or Reasonable Accommodation information.