Specialty Pharmacy Prior Authorization Specialist
- Category
- Pharmacy Technicians
- Job Type
- Full time
- Job ID
- R-15509
If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One!
We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South.
A Brief Overview
Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.
What you will do
- Responsible for precertification of eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity. Ensures medical documentation is sufficient to meet insurer guidelines for medical necessity documentation and procedure payment.
- Reviews clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of prescription medications.
- Assists with patient assistance and grant coordination for Patients for outpatient pharmacies from designated areas.
- Proactively analyzes information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines. Verifies physician orders are accurate. Determines CPT, HCPCS and ICD-10 codes for proper Prior Authorization.
- Contacts insurance companies and third party administrators to gather information and organize work-flow based on the requested procedure.
- Collects, reads and interprets medical documentation to determine if the appropriate clinical information has been provided for insurance reimbursement and proper charge capture.
- Serves as primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines. Establishes and maintains rapport with providers as well as ongoing education of providers concerning protocols for pre-certification.
- Communicates information and acts as a resource to Patient Access, Case Management, and others in regard to contract guidelines and pre-certification requirements.
- Performs research regarding denials or problematic accounts as necessary. Works to identify trends and root cause of issues and recommend resolutions for future processes.
Education/Formal Training Requirements
- Required - High School Diploma or Equivalent
Work Experience Requirements
- Required - Pharmacy (clinical, hospital, outpatient, or specialty) 3-5 years
Licenses and Certifications Requirements
- Required - Pharmacy Technician - Tennessee - Tennessee Board of Pharmacy
- Required - Certified Pharmacy Technician - Pharmacy Technician Certification Board
- Preferred - Certified Pharmacy Technician- ExCPT - National Healthcareer Association
- Preferred - Pharmacy Technician - Mississippi - Mississippi Board of Pharmacy
Knowledge, Skills and Abilities
- Basic understanding of prescription processing flow. Expertise in utiliizing EMRs to document clinical critieria required for third party approval.
- Knowledgeable of medical terminology, drug nomenclature, symbols and abbreviations associated with pharmacy practice.
- Strong attention to detail and critical thinking skills.
- Ability to speak and communicate effectively with patients, associates, and other health professionals.
- Ability to diagnose a situation and make recommendations on how to resolve problems.
- Experience with a computerized healthcare information system required. Familiarity with fundamental Microsoft Word software.
- Excellent verbal and written communication skills.
Supervision Provided by this Position
- There are no lead or supervisory responsibilities assigned to this position.
Physical Demands
- The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
- Must have good balance and coordination.
- The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
- The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
- The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative.
Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity.
Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community.
Don’t See What You’re
Looking For?
Sign up for job alerts and we’ll notify you when new roles become available.
Explore the World of MLH
-
Career Areas at Methodist Le Bonheur Healthcare
Explore rewarding careers at Methodist Le Bonheur Healthcare. Discover nursing, allied health, and support roles with opportunities to grow and make a difference.
-
Benefits
Learn all about the great benefits that every member of our team is entitled to.
-
Our Culture
We’re committed to a community where everyone belongs and can make an impact.
-
Learning & Development
At Methodist Le Bonheur Healthcare, we want everyone to reach their highest and greatest potential. Our system is filled with a variety of roles that allow for upward and lateral mobility. We support career advancement and promote from within. And we provide many programs for career entry, education, training and advancement.
-
Our Locations
Get a closer look at the vibrant and historical city that we are proud to call home.
-
Contact Methodist Le Bonheur Healthcare
Reach out for support in your career search and application process.
-
Our Stories
A place to find all of our sites content in a filterable, browsable blog like homepage.
-
Hub Headline
Lorem ipsum dolor sit amet, consect etur dipsce adipiscing elit. Phasellus iaculis nisi nec mauris fringilla vas ettenum al vestibullum.
-
Hub Headline
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Vestibulum nec enim hendrerit justo viverra aliquet. Suspendisse potenti. Donec efficitur vel mauris in aliquet.
-
Hub Headline
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Vestibulum nec enim hendrerit justo viverra aliquet. Suspendisse potenti. Donec efficitur vel mauris in aliquet.
-
Nursing Careers at Methodist Le Bonheur Healthcare
Join a team of highly skilled, compassionate nurses empowered by advanced resources, ongoing education, and a supportive environment. Explore diverse specialties from emergency and critical care to women’s services and surgical nursing and discover opportunities to grow your career through externships, residencies, and leadership pathways.
-
Explore Memphis
Learn the advantages of living in Memphis.
Jobs for You
-
attendant
- Memphis, Tennessee
- Environmental Services
-
Attendant
- Memphis, Tennessee
- Environmental Services
-
Registered Respiratory Therapist | Certified Respiratory Therapist | RRT|CRT | Le Bonheur Children's | FT | Night
- Memphis, Tennessee
- Respiratory Services
You have not viewed any jobs yet.
You have not saved any jobs yet.