Prior Authorization Specialist

<strong>At Emergent Holdings, we&rsquo;re creating an innovative environment where our employees belong authentically, contribute meaningfully, and thrive intentionally &mdash; both personally and professionally.</strong>

Southfield, USA

Emergent Holdings

<p class="p1"><strong>Emergent Holdings is driven by a singular goal &mdash; improving the health and safety of our customers and our communities. How do we do that? We create innovative insurance products, technology solutions, and services to support our key stakeholders &mdash; individuals, employers, providers, and strategic partners &mdash; improving the health and safety of the people and places we serve.</strong></p>

keywords: job description,claims,analysis,authorization,operations,education & experience,knowledge,skills


Competitive Compensation and Benefits Package

Overview: <br />Support BCBSM and BCNA providers (physicians and other healthcare providers rendering medical care) with Medicare Part B drug coverage inquiries, and prior authorizations.<br /><br /><strong><br />WORKING CONDITIONS:<br /><br /></strong> <p>Work is performed in an office setting with no unusual hazards.</p>
Responsibilities: <br /> <ul> <li>Answer telephones in an efficient and timely manner in a helpdesk setting, to lend appropriate assistance to providers that may call in with inquiries.</li> <li>Process prior authorization requests under the supervision of a Clinical Pharmacist and other support staff.</li> <li>Apply prior authorization criteria used within the online web tool to reach a decision, upload documentation, and provide support as needed to clinical staff.</li> <li>Assist providers with medical claims issues related to adjudication system for prior authorized specialty medications.</li> <li>Assist claims areas by pricing NOC drugs in a timely manner to meet service level agreements.</li> <li>Analyzing written, faxed, and verbal inquiries which may lead to entry of medical authorizations into the online provider-facing webtool.</li> <li>Communicate organization determination status to physicians and/or their staff and effectuate such decisions within the authorization online tool.</li> <li>Troubleshoot problems, inquiries, and new processing procedures for organization determinations.</li> <li>Perform operational tasks such as tracking error reporting, eligibility feeds, authorization files, to ensure the program operates smoothly.</li> <li>Assist operational staff with user interface testing for new drug additions to the program as needed.</li> <li>Perform other related duties as assigned.</li> </ul>
Requirements: <br /><strong>EMPLOYMENT QUALIFICATIONS: EDUCATION OR EQUIVALENT EXPERIENCE:<br /><br /></strong> <ul> <li>High School Graduate or GED equivalent required.</li> <li>Two (2) years of college preferred.</li> </ul> <br /><strong>EXPERIENCE:<br /><br /></strong> <ul> <li>Four (4) year&rsquo;s experience in retail or hospital Pharmacy required.</li> <li>Pharmacy Technician Certification (PTCB) preferred.</li> <li>Knowledge of specialty prescription drug names,&nbsp;NDC drug codes, therapeutic classes, and claims processing preferred.</li> <li>Experience with Specialty Medications is preferred.</li> <li>Experience with Medicare Part B medical benefits preferred.</li> </ul> <br /><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:<br /><br /></strong> <ul> <li>Knowledge of pharmacy and/or medical claims processing</li> <li>Understanding of formularies and utilization management edits</li> <li>Familiarity with Medicare Guidelines and Timeframes</li> <li>Proficient in Microsoft Office products</li> <li>Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.</li> <li>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.</li> </ul>