Prior Authorization Specialist

<p>With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.</p>

Detroit, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />Learn more about your options as an external candidate. <a href="" target="_blank" rel="noopener noreferrer">Click here</a> to view open positions.&nbsp;

keywords: support,process management,performance,management,claims,analysis,communication,support,knowledge,experience,education,organization,technology,certification


Competitive Total Compensation Package

Overview: <p>Support BCBSM providers (pharmacists and physicians) with Medicare Part D and/or Commercial pharmacy/ specialty drug benefits analysis, drug coverage inquiries and prior authorizations.</p>
Responsibilities: <ul> <li>Answer telephones in an efficient and timely manner to lend appropriate assistance to providers. Triage prior authorization requests under the supervision of a Clinical Pharmacist.&nbsp;</li> <li>Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy/specialty claims.&nbsp;</li> <li>Analyzing written inquiries which lends to entry and updating of pharmacy authorizations into the claims system.&nbsp;</li> <li>Communicate coverage determination status to physicians and/or members and effectuate such decisions within the authorization tool.</li> <li>Troubleshoot problems, inquiries, and new processing procedures for coverage determinations. Assist with internal control systems and regulations compliance.&nbsp;</li> <li>Perform other related duties as assigned.</li> </ul>
Requirements: <ul> <li>&nbsp;High School Graduate of GED equivalent required. Two (2) years of college preferred.</li> <li>&nbsp;Two (2) years experience in retail or hospital Pharmacy required.</li> <li>&nbsp;Pharmacy Technician Certification (PTCB) preferred.</li> <li>&nbsp;Knowledge of prescription drug names, therapeutic classes and claims processing.</li> <li>&nbsp;Experience with Medicare Part D prescription benefits may be preferred for some positions.</li> <li>&nbsp;Other Skills and Abilities</li> <li>Expert knowledge of pharmacy claims processing.</li> <li>Understanding of formularies and utilization management edits.</li> <li>Familiarity with pharmaceutical manufacturers and product/cost information.</li> <li>Computer Literate (Microsoft Office Products).</li> </ul> <p><em>All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.</em></p> <ul> <li>Job: Pharmacy Services</li> <li>Primary Location: Detroit</li> <li>Organization: Pharmacy Services-2121</li> <li>Schedule: Full-time</li> </ul> <p>&nbsp;</p>