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: support,process,performance,procedure,analysis,communication,experience,education,certification,knowledge


Competitive Compensation and Benefits Package

Overview: Support BCBSM and BCNA providers (pharmacists and physicians) with Medicare Part D drug coverage inquiries, Grievances, and prior authorizations.
Responsibilities: <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&nbsp; PA requests.</li> <li>Analyzing written, faxed, and verbal inquiries which leads 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: <p><strong>EMPLOYMENT QUALIFICATIONS:</strong></p> <p><strong>EDUCATION OR EQUIVALENT EXPERIENCE:</strong></p> <p>High School Graduate of GED equivalent required. Two (2) years of college preferred.</p> <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 D prescription benefits may be preferred for some positions</li> </ul> <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.&nbsp; Ability to write simple correspondence.&nbsp; 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.&nbsp; Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.</li> </ul>