JOB SUMMARY:
The Prior Authorization and Insurance Specialist is responsible for reviewing, submitting, monitoring, and responding to issues regarding medication prior authorizations for Cascade patients. This position works closely with the Clinical Care and Pharmacy Teams on patient insurance, authorization issues, billing issues, and required forms. Reviews patient history to identify supporting documentation in the patient chart relevant to the medication up to and including medical records, prescriptions, prior authorizations, insurance information and verifications, and management of pertinent forms required for (or involved in) patient care by uploading pertinent documentation to patient charts in the relevant software programs. Works closely with patients, Hemophilia Treatment Centers, and insurance companies to obtain prior authorizations and to resolve problems.
MINIMUM COMPETENCIES:
1. Education: Licensed and certified Pharmacy Technician required
2. Experience:
a. Minimum of three years of experience in a medical or non-profit setting working with insurance companies
b. Excellent written and oral communication skills
c. Proficiency in Microsoft Office Suite
POSITION REQUIREMENTS:
- Knowledgeable in medical terminology.
- Proficient knowledge of major health plans and insurance processes.
- Proficiency in operating a standard desktop and Windows-based computer system.
- Excellent communications skills in both written and verbal forms, including proper phone etiquette. Ability to read, understand and respond to detailed written and oral instructions.
- Excellent attention to detail
- Ability to work collaboratively in a team-oriented environment; displays courteous and friendly demeanor.
- Good organizational and time management skills to effectively juggle multiple priorities, time constraints and ever-changing situations.
- Ability to exercise sound judgement and problem-solving skills.
- Ability to perform mathematical calculations needed during the course of performing basic job duties.
- Knowledge of the compliance aspects of clinical care and patient privacy.
- Ability to handle patient and organizational information in a confidential manner.
- Knowledge of or willingness to learn various software programs required by insurance companies to submit prior authorizations and check eligibility (CoverMyMeds, Availity, etc).
JOB RESPONSIBILITIES:
1. Coordinate with appropriate parties when necessary such as Hemophilia Treatment Center and insurance, to complete prior authorizations. Advocate for the patient to the best of our ability on the prior authorizations and when communicating with insurance companies. Professionally communicates with the ordering provider, HTC staff and representatives of insurance companies, including both oral and written communication.
2. Updates information in patient medical record in Cascade pharmacy software and Epic EHR with prior authorization approval or denial information; follows up with HTC as to status and/or issues with prior authorizations. Advises the HTC with potential next steps, such as appeals.
3. Monitors in basket, email, fax, and teams messages, and follows up on correspondence timely and accurately.
4. Assists in all aspects of new patient intake
5. Supports team with annual patient mailings and forms, coordinate with Forms Committee and Compliance about new forms, adjustments to current forms, and changes in processes.
6. Monitor the schedule for daily orders and coordinate with team members to dispense workload.
7. Assist the Pharmacy Technicians when billing issues arise, by calling insurance companies, requesting overrides (high cost overrides, Pillar and SaveOn overrides) when necessary, updating insurance processing information in the internal system, or provide general help getting a claim to process.
8. Develops, implements and revises electronic forms via HIPAA compliant software, working in conjunction with the Forms Committee
9. Monitors and manages electronic form responses and files into EMR accordingly
10. Keep up to date with insurance changes and requirements.
11. Advise the Pharmacists and Clinical Care team when questions come up regarding insurance coverage for a new medication, dose change, out of pocket costs, or other prior authorization/insurance questions.
12. Inform the HTC when new insurance is discovered for a patient of theirs and advise them of next steps to get medication covered. Discuss whose program the patient will be on with the HTC.
13. Monitor monthly PA expirations, verify active insurance, and create referrals in current software. Assign the PA referrals to the appropriate team member to ensure PA’s are submitted in a timely manner to avoid interruptions in patient care.
14. Be able to identify underinsured new or current patients, and coordinate with Patient Access team for support.
15. Supports other teams as needed such as answering telephones when necessary, filing paperwork, etc.
Job Type: Full-time
Pay: $41,600.00 - $70,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Parental leave
- Vision insurance
Application Question(s):
- This position is full-time and requires regular, in person attendance at our Ann Arbor, MI office. Please confirm your current location. Only candidates in close geographical proximity to Ann Arbor will be eligible for consideration.
Experience:
- Prior Authorization: 2 years (Required)
License/Certification:
- Pharmacy Technician License (Preferred)
Work Location: In person
