Excellus Health Plan Inc.
Pharmacy Prior Authorization Technician I/II/III- 011591 (Healthcare)
The Pharmacy Prior Authorization Technician performs functions as permitted by law including the initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed utilizing pharmacy management drug policies and procedures. This position accurately prepares and interprets cases for UM reviews and determination. In addition, the Technician is the content expert for the applications used to process these requests. The Technician acts as a resource for staff regarding members' specific contract benefits, consistent with products, policies and procedures and related health plan functions such as member services, claims, and the referral/authorization process. This position provides leadership and expertise in the intake area of the prior authorization process for medications processed either through the pharmacy or medical benefit and in processing exception/prior authorization requests that follow standard protocols.
All Levels:
· Conducts an initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member's benefit.
· Routes cases directly to the pharmacist/medical director for final determination, as directed.
· Issues verbal and written member notification, as required.
· Reviews and interprets prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of prior authorization review is required, documents any relevant medication history and missing information to assist the pharmacist/nurse/physician in the review process.
· Develops and implements process improvement to increase efficiency in the review process for the clinical staff.
· Works with requesting providers, clinical pharmacists and other internal staff, as appropriate, in determining whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy and specific coverage criteria. Is able to point out nuances that may not be readily apparent regarding the request.
· Contacts pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed through the point of sale system and/or medical claim system in order to optimize the member experience.
· Acts as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy and/or medical claims with prior authorization information on file or needed for the member.
· Responsible for assuring appropriate auth entry across all lines of business. Ensure care management system interfaces to claim processing system for claim payment. Manual manipulation of auth may be required upon case completion.
· Performs system testing as required for upgrades and enhancements to the care management system.
· Acts as a content expert for prior authorization intake for our customers, both internal and external. Serves as department subject matter expert for pharmacy and medical drug authorizations and coverage.
· Serves as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems to troubleshoot. Triages issues to the appropriate department for resolution.
· Triages prior authorization workflow on a daily basis by rerouting cases, alerting clinical staff of time frame deadlines, monitoring work queues and keeping management aware of issues related to compliance mandated time frames for review completion.
· Provides phone coverage for incoming calls as required to support the UM process. This may include authorization inquiries and information requests, claim inquiries, and other related inquiries. Provides friendly, accurate, and timely assistance.
· Supports medical and pharmacy drug pricing questions, and uses drug lookup tools such as government sites, and other online resources.
· Maintains thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures in order to identify eligibility and coverage and assisting other staff with related inquiries.
· Performs unit specific workflow processes consistent with corporate medical & administrative policies, employer specific guidelines, and/or regulatory agencies.
· Produces, records, or distributes information for others. On a periodic basis, tracks and reports department performance against benchmarks.
· Prepares and assists in handling correspondence. Assures accuracy and timeliness of processing
· Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Examples: Utilization Management, Quality Management, and Case Management
· Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
· Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
· Regular and reliable attendance is expected and required.
· Performs other functions as assigned by management.
Level II (in addition to Level I essential responsibilities/accountabilities):
Level III (in addition to Level II essential responsibilities/accountabilities):
o Identifies, recommends and assesses new processes as necessary to improve productivity and gain efficiencies.
o Assists in updated departmental policies, procedures and desktop manuals relative to the functions.
o Identifies and develops processes and guidelines for performance improvement opportunities for the Utilization Management Department.
o Functions as a backup to the supervisor for testing and implementation of system upgrades.
Minimum Qualifications:
NOTE:
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.
All Levels:
Level I:
· High school diploma with a minimum of two years' experience in health-related field is required. Associates degree strongly preferred. A Bachelor's Degree will be accepted in lieu of experience.
· Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist, CPC background strongly preferred.
Level II (in addition to Level I minimum qualifications):
· Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist required. Proven job-based proficiency in a health care related field can be substituted for the requirement.
· Basic understanding and interpretation of medical terminology and diagnosis codes required
· Basic understanding of drug classes and therapeutic interchange as described in the drug policies.
· A clear understanding of prescription and medical benefits as it applies to the utilization review process.
· Must demonstrate proficient experience with the Microsoft Office suite.
· Strong verbal and written communication skills are required.
· Must possess a high degree of professionalism, strong work ethic and the ability to maintain a positive attitude when working with internal and external customers.
· Must be conscientious, efficient and accurate in prior authorization, exception and medical/Rx necessity review processing.
· Continually strive to develop and/or refine skills necessary to respond to customers.
· Must possess strong customer service orientation and the ability to interface effectively with internal and external customers.
· Capable of working independently and applying problem solving and analytical abilities
Level III (in addition to Level II minimum qualifications):
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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
Non Manager