Prior Authorization Specialist

The Prior Authorization (PA) Specialist is responsible for verifying eligibility, obtaining insurance benefits, and ensuring pre-certification, authorization, and referral requirements are met prior to the delivery of medication. The PA Specialist provides detailed and timely communication to both payers and clinical partners to facilitate compliance with payer contractual requirements and is responsible for documenting the appropriate information in the patient's record.

ESSENTIAL FUNCTIONS (These duties must be performed with or without reasonable accommodation. This document in no way states or implies that these are the only duties to be performed by the employee occupying this position):

1. Engage directly with practice management and staff to understand process and workflow and adapt pharmacy process for maximum support, capture, and production.
2. Verify insurance eligibility and benefit levels to ensure adequate coverage for identified medications.
3. Work with payers via electronic, telephonic, and/or fax communications,
4. Responsible for verification and investigation of pre-certification, authorization, and referral requirements.
5. Coordinate and supply information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits.
6. Collaborate with designated clinical contacts regarding encounters that require escalation.
7. Communicate with patients, clinical partners, financial counselors, and others as necessary to facilitate authorization process.
8. Facilitate submission of clean claims and reduction in payer denials by adhering to both organizational policies and procedures and maintaining productivity and quality goals.
9. Coordinate with the pharmacy wholesaler and/or manufacturer for the acquisition of medications for the pharmacy as needed.
10. Coordinate and triage prescription orders to other pharmacy partners when appropriate.
11. Appropriately prioritize workload to ensure the most urgent cases are handled in a timely manner.
12. Analyze service environment and offers resources or tools to enhance productivity.
13. Answer provider, staff, and patient questions surrounding insurance authorization requirements.
14. Collaborate with respective team to provide high impact problem resolution.
15. Build and maintain strong business relationships with key accounts (patients, providers, pharmaceutical manufacturers) across multiple settings.
16. Clarify prescription orders with pharmacist and/or clinician when necessary.
17. Provide exceptional care and support to internal and external customers.
18. Serve as a trusted advisor in the PA process both internally and externally.
19. Serve as a resource for pharmacy benefit information, clinical and program information.
20. Promptly report any allegations of impropriety to the Compliance Department.
21. Observes safety and security procedures, reports potentially unsafe conditions.
22. Comply with VytlOne’s Ethical Business Conduct policy and VytlOne’s Compliance Program.
23. Remain free from exclusion under the OIG and SAMS Medicare/Medicaid lists.
24. Complete required training, as assigned, within the established timeframes.
25. Demonstrate accuracy and thoroughness; display commitment to excellence; look for ways to improve and promote quality; apply feedback to improve performance; monitor own work to ensure quality.
26. Treat people with respect; work with integrity and ethically; uphold organizational values; manage financial resources in prudent manner, follow company cash management policies and procedures; compliant with all applicable regulations, including but not limited to, PHI, HIPAA, and State Board of Pharmacy.
27. Must be able to cope with the mental and emotional stress of the position.
28. Maintain regular attendance in accordance with established policies.
29. Perform other job-related duties as assigned.

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Education: High School Diploma or equivalent.  Registered as a Pharmacy Technician and in good standing with the State Board of Pharmacy preferred; Certified Pharmacy Technician if required by state law.

Experience: 2 or more years of experience in a retail pharmacy setting, medical billing and insurance verification, or working knowledge of the 340B Drug Pricing Program preferred

Knowledge, Skills, and Abilities:

• Ability to add, subtract, multiply and numbers, and divide in all units of measure using whole common fractions and
• Working knowledge and experience with pharmacy software, Microsoft Word and the
• Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure Able to speak effectively to customers or other members of the organization.
• Ability to learn and apply new skills; requires minimal supervision; displays understanding of how job relates to others; uses resources
• Ability to express ideas and thoughts verbally and in written form; exhibits good listening and comprehension; keeps others adequately informed; selects and uses appropriate communication
• Ability to display courtesy and sensitivity; manages difficult or emotional customer situations; responds promptly to customer needs; solicits customer feedback to improve service; maintains confidentiality.
• Ability to responds to requests for service and assistance; follows instructions, responds to management direction; takes responsibility for own actions; commits to doing the best job possible; meets attendance and punctuality expectations.
• Ability to approach others in a tactful manner; to react well under pressure; to treat others with respect and consideration regardless of their status or position; to accept responsibility for own actions; follows through on commitments; looks for ways to improve and promote quality; exudes professionalism consistent with company standards, in dress, personal appearance, and grooming.

We Offer:

At VYTLOne, we foster a diverse and progressive culture that promotes a work-from-home model and a "dress-for-your-day" approach to work attire. Our team-oriented environment encourages collaboration and innovation.  

We offer highly competitive compensation and comprehensive health benefits including:

• Comprehensive mental health and wellbeing resources
• Nationwide Blue Cross Blue Shield PPO with employee-friendly plan design, including a $850 individual annual medical deductible and $25 office visit copays, with low biweekly premiums
• Company-paid basic life/AD&D, short-term and long-term disability insurance
• Rx, dental, vision, other voluntary benefits, and FSA
• Employer-matched 401k Plan
• Industry-leading PTO plan
• And more!

Apply today at:  https://www.maxor.com/careers/     

VYTLOne is an EOE, including disability/vets