JOB DESCRIPTION
The Prior Authorization Representative is responsible for verifying prior authorization requirements and obtaining authorization when required. Works directly with physician offices and payers to facilitate patient access to various therapies. Representative will ensure patient insurance coverage and benefits, identify requirements for prior approval and submit for authorization. Assists with appealing prior authorization denials, retro authorization or other special cases
Responsibilities Include, But Are Not Limited To
Validates insurance patient s coverage, communicate any issues with benefits or coverage to the appropriate managers
Checks the requirements for prior authorization and initiates as required
Coordinates required paperwork, clinical notes and forms for submission to support request and initiates as required
Follows up frequently to ensure visibility on authorization status throughout the approval process
Basic knowledge payer payment process with detailed knowledge on the payer prior authorization process
Basic ICD9/10 and CPT code familiarity, expert knowledge on subset of our client therapy codes
Superior customer service skills with outstanding communication skills to use with various stakeholders; physicians, sales representatives, payer representatives, utilization reviewers, various internal and external stakeholders,
Advanced Microsoft Excel skills. Ability to learn and use multiple CRM software programs as needed
Good organizational skills with ability to handle multiple inquiries at the same time and critical problem-solving skills with high attention to detail
Responsibilities may include the following and other duties may be assigned. Represents company to external and internal customers, answers productrelated questions, traces lost shipments, interprets and clarifies customer orders for the shipping department, takes orders over the phone when necessary. May manage webbased ordering, confers with management regarding customer credits, returns goods for credit, identifies quality assurance complaints, and writes price differentials on mail orders. May approve allocation of stock in short supply, special price quotations and bids, pricing allowances, deductions and adjustments. May manage inventories at customer facilities using EDI (electronic data interchange), forecasting, replenishment and inventory systems, focusing on stock and allocation issues to maximize service levels. OFFICE SUPPORT CAREER STREAM: Individual contributors who provide organizational related support or service (administrative or clerical) for other members within the organization. The majority of time is spent in the delivery of support services or activities, typically under supervision. DIFFERENTIATING FACTORS Autonomy: Established and productive individual contributor. Works on clerical and administrative assignments that may require application of prior experience. Works under moderate supervision, making minor adjustments to methods and processes. Organizational Impact: Works to deliver on daytoday objectives with direct impact on achievement of results for the job area, including moderate scheduling or customer satisfaction implications. Work consists of tasks that are typically routine, with some deviation from standard practice . Innovation and Complexity: Checks and makes minor adjustments to work methods to solve problems that are routine and typically exist in current work processes and systems . May be required to highlight areas of concerns/problems and puts forth solutions in own job area. Communication and Influence: Communicates typically with internal contacts within and outside of immediate team. Obtains and provides information requiring some explanation or interpretation . Leadership and Talent Management: May provide guidance and assistance to new or entry level employees. Required Knowledge and Experience: Requires full job knowledge of systems and procedures obtained through prior work experience or education. Requires minimum of 2 years of relevant experience.