Prior Authorization Coordinator I

Job Description:

Job Description

Summary

Works as a member of the Laker Clinical Operations team. Processes Coverage Determination, Appeal and Grievance (CDAG); and Direct Member Reimbursement (DMR) requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments. Uses various business applications to perform analysis, obtain information, and enter data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make processing determinations based upon clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.). Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality. Works under general supervision, relying on instructions, work process guidelines, policies & procedures, and company knowledge/experience to perform the functions of the job. Extent of supervision ranges from close, to moderate, to minimal oversight based upon demonstrated skill and performance levels as defined for the position. This position is part of a three-level career path with progression opportunities described in the Core Processing Career Path/Succession Planning Guidelines.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Process and finalize requests within clients’ turnaround time (TAT) and Performance Guarantees (PGs) utilizing guidelines. Enter requests into the system and prioritize requests. Check formulary alternatives, review tried and failed medications. Utilize drug references and verify the drug being requested is indicated and approved for the condition. Document all related information processing. Respond to requests by faxing or mailing status of the request to the member, physician or pharmacy.
• Conforms to defined roles & responsibilities and rules of engagement between processing and clinical decision making. Partners with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing as necessary.
• Accountable to achieve processing productivity and accuracy standards.
• Analyzes, researches, and resolves processing issues as appropriate for experience and career path level, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from team subject matter experts (SME) or supervisor; and referring unique or high dollar requests to supervisor according to guidelines.
• Coordinates notifications to members, physicians, and pharmacies as required to obtain missing information, manage pended requests, and communicate determinations. Documents request related information and status. Make outbound calls to obtain information and answer questions about request status.
• Collaborates with Account Management team to understand PBM clients’ processing requirements and expectations. As appropriate for experience and career path level, partners with client teams to complete special prior authorization processing projects and provide accurate, timely, and reliable information to client claim inquiries.
• Collaborates with Contact Center Services in resolving inquiries
• Protects and maintains confidentiality and privacy of all member information, including following strict protocols for date stamping and storage/security of request forms and related information.

Supervisory Responsibilities

No supervisory responsibilities

                                   

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written).  One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

GED/HS Diploma and 1+ year experience or equivalent combination of education and experience

Computer Skills

Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs. Experience with Windows based database programs is also required.

Certificates, Licenses, Registrations

Successfully complete one of the national certification exams OR obtain state licensure (in an U.S. State or Territory) preferred.  If applicable, a current Pharmacy Technician License and/or CPhT certification without restriction.

Other Skills and Abilities

• Demonstrates ability to appear for work on time, follow directions from a supervisor, interact well with co- workers, understand and follow work rules and procedures, comply with corporate policies, goals and objectives, accept constructive criticism, establish goals and objectives, and exhibit initiative and commitment.
• Understanding of managed pharmacy benefit concepts including formularies, prior authorizations, edits, and claim adjudication. Working knowledge of customer service in a retail/outpatient pharmacy environment. Familiarity with pharmacy software data submission requirements. Self-starter with the ability to work independently and as part of a team that includes clinical pharmacists and other PACs. Attention to detail with a high degree of accuracy. Ability to prioritize and multi-task when presented with multiple duties.

Reasoning Ability

•  Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Ability to deal with problems involving a few concrete variables in standardized situations.

Mathematical Skills

•  Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Language Skills – Choose up to 1 from each drop-down list.    

• Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. 
• Ability to effectively present information to top management, public groups, and/or boards of directors.

Competencies To perform the job successfully, an individual should demonstrate the following competencies:

• Composure
• Decision Quality
• Organizational Agility
• Problem Solving
• Customer Focus
• Drive for Results
• Peer Relations
• Time Management
• Dealing with Ambiguity
• Learning on the Fly
• Political Savvy

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is a full-time non-exempt position requiring one to be able to work overtime from time to time in order to get the job done.  Therefore, one must have the ability to work nights, weekends or on holidays as required.  This may be changed at any time to meet the needs of the business.  The core business hours for this position are 6:00 AM to 7:00 PM EST seven days per week. Shifts are scheduled throughout this period based on business needs.

Travel

This position requires no travel however attendance maybe required at various local conferences and meetings.

The Perks:

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to www.medimpact.com/careers

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego,
California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.