Top 17 Prior authorization specialist Jobs in San Rafael, Ca

Operations Specialist, Experienced
Blue Shield of California —Oakland, CA
- $32.03 - $48.04 an hour
- Full-time
- Hybrid work
- Background check
- Microsoft Excel
- Microsoft Outlook
- Work from home
6d
Operations Specialist, Senior
Blue Shield of California —Oakland, CA
- $81,950 - $122,870 a year
- Full-time
- Hybrid work
- Background check
- Microsoft Excel
- Microsoft Outlook
- Work from home
6d
Prior Authorization Specialist
PHIL —San Francisco, CA
- $19 - $22 an hour
- Full-time
- Mid-level
- Office
- Reliable transportation
Quick Apply
Medication Access Technician
University of California San Francisco —San Francisco, CA
- Full-time
- Spanish
- Writing skills
- Basic math
Clinical Support Specialist
PHIL —San Francisco, CA
- $26 - $28 an hour
- Full-time
- Remote
- Continuous improvement
- 2 years
- Communication skills
- Health insurance
- Dental insurance
Quick Apply
DME Documentation Criteria Reviewer
Hike Medical —San Francisco, CA
- $90,000 - $145,000 a year
- Full-time
- Hybrid work
- Mid-level
- Office
- Commercial
Member Services Representative – Temporary Full Time
CCHP Health Plan —San Francisco Bay Area, CA
- $24.00 - $39.39 an hour
- 8 hour shift
- Spanish
- English
- Research
Quick Apply
Clinical Informatics Specialist
Latent —San Francisco, CA
- $75,000 - $100,000 a year
- Full-time
- Continuous improvement
- Quality control
- Epic
10d
Epic Ambulatory Bones Application Engineer Specialist - 6079188
Accenture —San Francisco, CA
- $47.85 - $57.85 an hour
- Full-time
- Remote
- 5 years
- High school diploma or GED
- US work authorization
- Disability insurance
- Health insurance
Professional Fee Coder - Analyst II (part-time / per diem)
University of California San Francisco —Emeryville, CA
- From $45 an hour
- Full-time
- Anatomy knowledge
- Mid-level
- Bachelor's degree
Software Engineer (Agent) Onsite (San Francisco, CA)
Parakeet Health —San Francisco, CA
- $150,000 - $200,000 a year
- Full-time
- Mid-level
- Office
- In-person
- Commuter assistance
- Dental insurance
Director of Customer Success
Valency Systems Inc. —Berkeley, CA
- Full-time
- Hybrid work
- US work authorization
- Senior level
- Commercial
Quick Apply
11h
Forward Deployed Engineer
RRC —San Francisco, CA
- $160,000 - $1,900,000 a year
- Full-time
- System design
- Mid-level
- SQL
Quick Apply
7d
Medical Billing Specialist, Orthopedics, (Novato), Full-Time, Days
MarinHealth Medical Network —Novato, CA
- $23.00 - $31.73 an hour
- 8 hour shift
- Microsoft Excel
- Customer service
- Writing skills
Quick Apply

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Operations Specialist, Experienced

Blue Shield of California -
Oakland, CA

Apply Now

Job Details

Full-time
$32.03 - $48.04 an hour
6 days ago

Benefits

Work from home

Qualifications

Microsoft Outlook
Cross-functional collaboration
Pharmacy Technician Certification

Full Job Description

Your Role

The Formulary Management team leads the development and maintenance of multiple formularies to support competitive health plan products, manage cost-of-healthcare, and meet regulatory requirements for all lines of business including Commercial Large Group, Commercial Small Group, Individual/Family plan, and Medicare. The Operations Specialist, Experienced will report to the Senior Manager of Formulary Management. In this role you will be a subject matter expert that will lead efforts with formulary for pharmacy claim adjudicator and other vendors to ensure maintenance, validation, and audits are compliant with business needs. You will support in the development and maintenance of the formularies for all Blue Shield lines of business - Commercial, Exchange, and Medicare. This role is responsible for supporting day-to-day operations, maintaining of formulary and drug list databases, supporting P&T materials and documentation, maintaining desk-level procedures as well as job aids, and creating reports. The Operations Specialist, Experienced will collaborate with the pharmacy claim adjudicator, analytics, benefits and claims, Pharmacy Market Experience, Compliance, prior authorization, and customer services departments to communicate formulary and utilization management changes, formulary intent, and to ensure that formulary decisions are implemented in accordance with business rules and regulatory requirements.

Your Work

In this role, you will:

Maintain formulary databases and associated utilization management edits related to weekly drug updates and required for business operations related to Formulary Management for Commercial, Exchange, and Medicare lines of business. Review systems and applications and recommend system edits/changes as needed
Act as subject matter expert and review operational workflows, identifying problems and develop improvements, modifications, and enhancements; identify technical formulary issues that would prevent or delay CMS approval of BSC formularies; notify appropriate managers of Medicare formulary issue requiring immediate attention for resolution; determine appropriate workflow required for maintaining formulary decisions
Develop and evaluates tools and materials that enhance operating efficiency and accuracy related to Formulary management, both internal to the team and across the department and in conjunction with external vendors used to manage and maintain the formulary for all lines of business.
Develop and transmit the documentation required to notify CMS of formulary, prior authorization criteria, and step therapy criteria changes.
Develop required Commercial and Medicare printed formulary documents and work with the Pharmacy Communications, Medicare Marketing, and Web/Mobile teams to make these documents available in print and online. Assist with updating content and web posting requirements including drug coverage requirements such as prior authorization and step therapy criteria.
Participate as a subject matter expert in the development of written guidelines and documents desk level procedures and policy and procedures
Maintain and adheres to regulatory requirements for Department of Managed Health Care (DMHC), Exchange, and Medicare as subject matter expert related to formulary submissions, notification to internal/external stakeholders of changes to utilization management edits, and generation/distribution of collateral, including letters, websites, and formulary PDFs.
Validate claims to ensure formulary implementation is consistent with formulary decisions and regulatory requirements
Coordinates operational implementation of formulary decisions as subject matter expert with internal teams (e.g, Drug Utilization Review, Pharmacy Benefit & Claims, Pharmacy Market Experience) and external teams (Pharmacy Benefits Adjudicator)
Act as subject matter expert of formulary operational workflows for implementing formulary decisions in compliance with state and federal regulations and audits
Occasional business travel required
Other duties as assigned.

Your Knowledge and Experience

Requires a bachelor’s degree or at least 3 years of equivalent experience
Requires at least 2 years of prior relevant experience within Pharmacy Services (e.g., claims, customer service, benefits, prior authorization, formulary)
Experience working with Pharmacy Benefit Management systems or vendors
Knowledge of Pharmacy Benefit design and Formulary configuration; knowledge of Blue Shield of California (or similar health care organization) pharmacy configuration is preferred
Requires California Pharmacy Technician Certification
Requires strong skills in standard Microsoft Office applications (e.g., Excel, Word, Outlook)
Requires strong coordination and interpersonal skills working in a matrixed environment with multiple stakeholders
Familiarity with Medispan drug files is preferred
Broad knowledge of technical and operational practices of formulary decision documentation, regulatory submission, and implementation in the claims processing system is preferred
Familiarity with Medispan drug files is preferred
Knowledge of Medicare Part D and Commercial formularies is preferred

ABOUT THE TEAM
About Stellarus and the Ascendiun Family of Companies

Stellarus, launched in January 2025, is designed to scale innovative healthcare solutions that support customers in creating a health care experience deserving of their family, friends, and neighbors.

Stellarus is part of a family of organizations that is overseen by a nonprofit corporate entity named Ascendiun. The Ascendiun Family of Companies also includes Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan and Altais, a clinical services company.

Stellarus’ vision is to empower its customers to create a healthcare experience that is worthy of their family, friends, and neighbors. Stellarus’ objective is to offer innovative, modern, scalable solutions that challenge the health care status quo. This very closely aligns with Blue Shield of California’s vision by using innovation to improve quality, affordability, and experience for members.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Our Values:

At Stellarus, our core values of agility, trust, drive, courage and service shape our approach to developing innovative product offerings.

Our Workplace Model:

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

For most teams, this means coming into the office two days per week.
Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Apply Now

Refine Your Search

prior authorization specialist jobs in san rafael, ca

Operations Specialist, Experienced

Operations Specialist, Senior

Prior Authorization Specialist

Medication Access Technician

Clinical Support Specialist

DME Documentation Criteria Reviewer

Member Services Representative – Temporary Full Time

Clinical Informatics Specialist

Epic Ambulatory Bones Application Engineer Specialist - 6079188

Professional Fee Coder - Analyst II (part-time / per diem)

Software Engineer (Agent) Onsite (San Francisco, CA)

Director of Customer Success

Forward Deployed Engineer

Medical Billing Specialist, Orthopedics, (Novato), Full-Time, Days

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