Prior Authorization Specialist
Diplomat Specialty Pharmacy - Flint, MI

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A Prior Authorization team member acts as liaison between a physician and insurance company in order to obtain an updated authorization for existing patients prior to current authorization expiration. The team member has knowledge of commonly-used concepts, practices, and procedures used within the insurance verification field. The team member relies on instructions and pre-established guidelines to perform the functions of the job and works under immediate supervision of the Medical Billing Required Department Supervisor.

REPORTING RELATIONSHIPS

This position reports to the MBR Supervisor.

There are no direct reports to this position.

REQUIREMENTS:
Education : High School Diploma or G.E.D required.

Licensing/Certification : Pharmacy Technician Certification is required. If not certified at time of hire, employee must obtain certification within 210 days of hire date.

Experience : Previous Pharmacy or medical verification experience is preferred.

Skills/Knowledge :
Knowledge of Third Party Payers including Medicaid, Medicare, Commercial, medical terminology and coding experience.

Strong customer service background.

Must be detail-oriented and be able to multi-task.

Be able to work well with various personalities and work as a team.

Should be independent and self-motivated – able to work and accomplish goals with little to no supervision.

Should be organized and able to prioritize and manage time effectively.

Must be dependable and maintain levels of confidentiality.

General knowledge of Internet navigation and research,

e-mail, fax transmission, and copy equipment are essential.

Physical : Sitting for prolonged periods of time, walking, standing, kneeling, crouching, stooping, and capable of lifting 35 pounds.

Mental : Basic math skills with the ability to compile, graph, and track different aspects of company information. Computer aptitude.

Language : Fluency in English with outgoing personality that translates to phone skills with excellent verbal and written communication skills.

Reasoning : Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.

Technology : Proficient in Windows based operating systems and Microsoft Office applications including Word, Excel, and Outlook.

WORKING CONDITIONS

A climate controlled office environment.

DUTIES & RESPONSIBILITIES

Assist in obtaining updated prescription authorization for existing patients prior to the current authorization expiration.

Assist the physician’s office in obtaining and completing any and all necessary documents including statement of medical necessity, prescription, etc. need for a re-authorization.

Act as a liaison between medical insurance or pharmacy benefit providers and physician’s office to aid in the process of obtaining a prior authorization when needed for the services to be rendered.

Communicate the insurance investigation outcome with the physician’s office and/or patients via phone, fax, or e-mail.

Operating eNav™ MBR Dashboard to perform job functions relative to documentation of benefits investigation.

Comply with all appropriate policies, procedures, safety rules and regulations.

Other Duties and Responsibilities as assigned.

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