Adjudication, Analysis Skills, Biotech and Pharmaceutical, Customer Support/Service, Customer Training, Formulary, Healthcare Management, Maintain Compliance, Medications, Operational Support, Operations, Pharmacy, Project/Program Coordination, Regulatory Requirements, Resolve Customer Issues, Utilization Management
Job Summary
Responsible for processing prior authorization requests and supporting pharmacy services, including claims analysis, reporting, and coordination of clinical programs. Ensures compliance with organizational goals and regulatory requirements.
Key Responsibilities
- Review and process prior authorization requests based on medical necessity and criteria
- Communicate with physicians, pharmacies, members, and internal teams regarding eligibility, coverage, and claims
- Facilitate formulary compliance and promote generic utilization
- Handle appeals, complaints, and compliance-related inquiries
- Support reporting, data requests, and special projects
- Assist with training for clients, members, and staff
- Support daily pharmacy operations and Medication Therapy Management (MTM) programs
- Recommend improvements to enhance efficiency and productivity
Education & Experience
- Bachelor s degree (preferred) in Healthcare Management, Business, or Pharmaceutical Administration
- Minimum 2 years of experience in:
- Prescription claims adjudication
- Pharmacy Utilization Management
- Prior customer service experience required
I
Integrated Resources, Inc