Position title
Prior Authorization Specialist
Description

The Prior Authorization Specialist is responsible for reviewing prior authorization requirements with a Clinical Innovation Pharmacist and addressing PA questions from members, providers (prescribers), pharmacy personnel, and Health Plans.

Responsibilities
  • Provide support for Clinical Programs to create and maintain prior authorization guidelines for clinical product offerings.
  • Gather all required information for the PA review.
  • Intake Prior Authorization requests from the phone and fax queue.
  • Review and approve physician inquiries for pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.
  • Conducts root-cause analysis for any issues associated with a PA request.
  • Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, financial, and operational effectiveness and quality.
  • Provides support for internal and external audits and surveys.
  • Maintain accurate and complete documentation of all inquiries for continuous improvement.
  • Follow all internal Policies & Procedures to ensure consistency, accuracy, and operational effectiveness.
  • Supports Fraud, Waste and Abuse program system oversight and communicates any suspected fraud discovered.
  • Follows all state and federal regulations applicable to PBM operations and utilization management.
  • Maintains quality service by enforcing quality and stakeholder service standards, analyzing, and resolving quality and stakeholder (member, client, pharmacy) service problems and recommending system improvements.
Qualifications
  • High school diploma or the equivalent required. Associate’s or bachelor’s degree is preferred
  • 2 – 5 years of pharmacy technician experience in a retail pharmacy, PBM, hospital, clinical pharmacy, or long-term care environment

Licenses/Certifications:

  • PTCB or equivalent certification required
  • Active Pharmacy Technician license (multiple states may be required)
  • Strong PC skills; MS Word, Excel, Access, and Power Point

Applicants must be able to pass a background investigation as all offers are pending a successful completion of background check per the company policy.

Job Location
Southborough, MA
Working Hours
Full Time
Date posted
August 19, 2020
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Position: Prior Authorization Specialist

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