Duties
As a licensed healthcare professional employed in the Prior Authorization Department, the primary responsibility is to make determinations on prior authorization requests for coverage of pharmaceutical products.
Determinations include medical necessity and benefit decisions.
Decisions are made in accordance with established pharmacy guidelines, prior authorization criteria, industry regulations, and sound clinical judgment.
Works independently with respect to reviews and decision-making, with the support of Pharmacist II (R)s and supervisors.
Works as a member of a team of peers committed to meeting or exceeding quality standards and customer performance guarantees.
This position includes a rotating weekend schedule if business needs dictate.
Additional responsibilities include
Provide clinical support to the Customer Care Center.
Engage providers in discussions to support determinations.
Support Fraud and Abuse program oversight.
Keep abreast of industry trends and regulatory changes.
Keep abreast of operational directives and customer reference materials.
Skills
No experience required, Prior Authorization or Coverage Determination experience preferred.
Proficient PC skills in a Windows-based environment.