Work Hours: Job Overview:
The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical information from electronic medical record, and timely communication with patients, prescribers and physician office staff. Candidates should possess knowledge of third-party reimbursement regulations and medical terminology as well as seek out assistance from a pharmacist or physician as necessary. Success in this role will require strong communication, interpersonal, and problem-solving skills. This person should be able to interact and communicate effectively with internal and external customers, physician office staff, and all members of the organization.
Essential Functions
Research and investigate Prior Authorization (PA) requirements by insurance company Obtain Prior Authorization status updates from the insurance company and communicate to patient, pharmacy, or physician’s office as necessary Submit Prior Authorization application forms and all required supporting documentation to the insurance company Review medical records to obtain necessary patient demographic and clinical information and seek timely clarification from pharmacist or physician as necessary Review Prior Authorization denials and communicate reasons for denial to physicians and patients Serve as a subject matter expert for drug formularies and the prior authorization process in general Follows up with insurance companies in a timely manner regarding Prior Authorizations Provides excellent customer service as evidenced by a willingness and ability to assist customers (both internal and external) with their questions/concerns, treating customers in a friendly and helpful manner, and maintaining a positive attitude
Job Requirements: High School Degree or GED in Pharmacy; Pharmacy Technician or Medical Assistant Certified Pharmacy Technician or Certified Medical Assistant desired Prior experience with medication Epic and/or prior authorizations desirable 2-3 years’ experience Clinical Pharmacy, Pharmacy Technician or Medical Assistant
Job Responsibilities: Demonstrates the ability to prioritize daily tasks and has a working knowledge of department’s day-to-day operations and initiatives. Is an active participant in meetings, work groups, and committees. Participates in departmental and organizational feedback opportunities. Assists in the training of new employees. Meets or exceeds department's internal quality performance metrics. Participates in quality improvement activities and projects to monitor the effectiveness of department's services. Meets or exceeds department’s customer satisfaction targets and goals. Assumes responsibility for achieving department satisfaction goals and demonstrates a commitment to service excellence for internal and external customers. Proactively communicates with patients and physician office staff. Serves as a subject matter expert for the prior authorization process. Meets or exceeds department’s goals for formulary adherence measures, and other cost control initiatives identified as a priority for the department. Works collaboratively with pharmacists, prescribers, physician office staff and all members of the health care team to coordinate all aspects of the prior authorization process and documents activities appropriately in the electronic medical record.
Other job-related information:
Working Conditions:
Climbing - Rarely
Concentrating - Frequently
Continuous Learning - Consistently
Hearing: Conversation - Consistently
Interpersonal Communication - Consistently
Kneeling - Rarely
Lifting <10 Lbs - Occasionally
Lifting 50+ Lbs - Rarely
Lifting 11-50 Lbs - Rarely
Pulling - Rarely
Pushing - Rarely
Reaching - Rarely
Reading - Consistently
Sitting - Consistently
Standing - Occasionally
Stooping - Rarely
Thinking/Reasoning - Consistently
Use of Hands - Consistently
Color Vision - Consistently
Walking - Rarely
TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:
Serve: ALWAYS…
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS…
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service
Respect: ALWAYS…
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS…
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community
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