Prior Authorization Specialist B

<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,analysis,support,education & experience,knowledge,skills


Competitive Compensation and Benefits Package

Overview: <br />Support BCBSM and BCNA providers (pharmacists and physicians) with Medicare Part B drug coverage inquiries, Grievances, and prior authorizations.<br /><br /> <p><strong>WORKING CONDITIONS:</strong></p> <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 to lend appropriate assistance to providers</li> <li>Process prior authorization requests under the supervision of a Clinical Pharmacist.</li> <li>Apply pharmacy prior authorization criteria used in the adjudication of pharmacy PA requests.</li> <li>Analyzing written, faxed, and verbal inquiries which lead to entry of pharmacy authorizations into the system.</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.</li> <li>Perform other related duties as assigned.</li> </ul>
Requirements: <br /> <p><strong>EDUCATION OR EQUIVALENT EXPERIENCE:</strong></p> <ul> <li>High School Graduate or GED equivalent required.</li> <li>Two (2) years of college preferred.</li> </ul> <br /> <p><strong>EXPERIENCE:</strong></p> <ul> <li>Two (2) years experience in retail or hospital Pharmacy required.</li> <li>Pharmacy Technician Certification (PTCB) preferred</li> <li>Knowledge of prescription drug names, therapeutic classes, and claims processing</li> <li>Experience with Medicare Part B prescription benefits may be preferred for some positions</li> </ul> <br /> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Knowledge of pharmacy claims processing</li> <li>Understanding of formularies and utilization management edits</li> <li>Familiarity with Medicare Guidelines and Timeframes</li> <li>Computer Literate (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>